Yoga treatment for chronic non-specific low back pain

Effectiveness and cost-effectiveness of offering a chair-based yoga programme in addition to usual care in older adults with multiple long-term conditions: a pragmatic, parallel group, open label, randomised controlled trial

Background

People with multiple long-term conditions are more likely to have poorer health-related quality of life (HRQOL). Yoga has the potential to improve HRQOL. Gentle Years Yoga© (GYY) is a chair-based yoga programme for older adults. We investigated the effectiveness and cost-effectiveness of the GYY programme in older adults with multiple long-term conditions.

Methods

In this pragmatic, multi-site, open, randomised controlled trial, we recruited adults aged ≥65 years with ≥2 long-term conditions from 15 primary care practices in England and Wales. Participants were randomly assigned to usual care control or a 12-week, group-based, GYY programme delivered face-to-face or online by qualified yoga teachers. The primary outcome was HRQOL (EQ-5D-5L) over 12 months. Secondary outcomes included anxiety, depression, falls, loneliness, healthcare resource use, and adverse events.

Results

Between October 2019 and October 2021, 454 participants were randomised between the intervention (n=240) and control (n=214) groups. Seven GYY courses were delivered face-to-face and 12 courses were delivered online. The mean number of classes attended among all intervention participants was nine (SD 4, median 10). In our intention-to-treat analysis (n=422), there was no statistically significant difference between trial groups in the primary outcome of HRQOL (adjusted difference in mean EQ-5D-5L = 0.020 [favouring intervention]; 95% CI -0.006 to 0.045, p=0.14). There were also no statistically significant differences in key secondary outcomes. No serious, related adverse events were reported. The incremental cost-effectiveness ratio was £4,546 per quality-adjusted life-year (QALY) and the intervention had a 79% probability of being cost-effective at a willingness-to-pay threshold of £20,000 per QALY. The intervention was acceptable to most participants and perceived as useful by some.

Conclusions

The offer of a 12-week chair-based yoga programme in addition to usual care did not improve HRQOL in older adults with multiple long-term conditions. However, the intervention was safe, acceptable, and probably cost-effective.

A review of the WHO strategy on traditional, complementary, and integrative medicine from the perspective of academic consortia for integrative medicine and health

Despite important progress in modern medicine, widely regarded as an indispensable foundation of healthcare in all highly advanced nations and regions, not all patients respond well to available treatments in biomedicine alone. Additionally, there are concerns about side effects of many medications and interventions, the unsustainable cost of healthcare and the low resolution of chronic non-communicable diseases and mental disorders whose incidence has risen in the last decades. Besides, the chronic stress and burnout of many healthcare professionals impairs the therapeutic relationship. These circumstances call for a change in the current paradigm and practices of biomedicine healthcare. Most of the world population (80%) uses some form of traditional, complementary, and integrative medicine (T&CM), usually alongside biomedicine. Patients seem equally satisfied with biomedicine and T&CM, but in the field of T&CM there are also many challenges, such as unsupported claims for safety and/or efficacy, contamination of herbal medicines and problems with regulation and quality standards. As biomedicine and T&CM seem to have different strengths and weaknesses, integration of both approaches may be beneficial. Indeed, WHO has repeatedly called upon member states to work on the integration of T&CM into healthcare systems. Integrative medicine (IM) is an approach that offers a paradigm for doing so. It combines the best of both worlds (biomedicine and T&CM), based on evidence for efficacy and safety, adopting a holistic personalized approach, focused on health. In the last decades academic health centers are increasingly supportive of IM, as evidenced by the foundation of national academic consortia for integrative medicine in Brazil (2017), the Netherlands (2018), and Germany (2024) besides the pioneering American consortium (1998). However, the integration process is slow and sometimes met with criticism and even hostility. The WHO T&CM strategies (2002-2005 and 2014-2023) have provided incipient guidance on the integration process, but several challenges are yet to be addressed. This policy review proposes several possible solutions, including the establishment of a global matrix of academic consortia for IM, to update and extend the WHO T&CM strategy, that is currently under review.

Appropriateness of exercise therapy delivery in chronic low back pain management: cross-sectional online survey of physiotherapy practice in Germany

BACKGROUND

In Germany, exercise therapy represents the most commonly prescribed physiotherapy service for non-specific, chronic low back pain (NSCLBP). So far, little is known about current practice patterns of German physiotherapists in delivering this intervention. Thus, the aim of this study was to investigate the appropriateness of exercise therapy delivered to NSCLBP patients in German physiotherapy care and to identify practitioner-related drivers of appropriate exercise delivery.

METHODS

We used a vignette-based, exploratory, cross-sectional, online-survey study design (76-items; data collection between May and July 2023). Eligible participants were required to hold a professional degree in physiotherapy and were required to be practicing in Germany. Access links to anonymous online surveys were spread via established German physiotherapy networks, educational platforms, social media, e-mail lists, and snowball sampling. Appropriateness of exercise therapy was calculated by an equally weighted total score (400 points) including scales on shared-decision-making, exercise dose selection, pain knowledge and self-management promotion. "Appropriate exercise delivery" was determined by a relative total score achievement of > 80%. "Partly appropriate exercise delivery" was determined by a relative total score achievement of 50-79%, and "inappropriate exercise delivery" by a score achievement of < 50%. Practitioner-related drivers of exercise appropriateness were calculated by bivariate and multiple linear regression analyses.

RESULTS

11.9% (N = 35) of 298 physiotherapists' exercise delivery was considered "appropriate", 83.3% (N = 245) was "partly appropriate", and 4.8% (N = 14) was "inappropriate". In the final multiple regression model, most robust parameters positively influencing appropriate delivery of exercise therapy were increased scientific literacy (B = 10.540; 95% CI [0.837; 20.243]), increased average clinical assessment time (B = 0.461; 95% CI [0.134; 0.789]), increased self-perceived treatment competence (B = 7.180; 95% CI [3.058; 11.302], and short work experience (B = - 0.520; 95% CI [-0.959; - 0.081]).

CONCLUSION

Appropriate exercise delivery in NSCLBP management was achieved by only 11.9% of respondents. However, the vast majority of 95.2% of respondents was classified to deliver exercise therapy partly appropriate. Long work experience seemed to negatively affect appropriate exercise delivery. Positive influences were attributed to scientific literacy, the average clinical assessment time per patient as well as the perceived treatment competence in NSCLBP management.

REGISTRATION

Open science framework: https://doi.org/10.17605/OSF.IO/S76MF .

Testing Biological and Psychological Pathways of Emotion Regulation as a Primary Mechanism of Action in Yoga Interventions for Chronic Low Back Pain: Protocol for a Randomized Controlled Trial

BACKGROUND

Interventions that promote adaptive emotion regulation (ER) skills reduce pain in patients with chronic pain; however, whether the effects of yoga practice on chronic low back pain (CLBP) are due to improvements in ER remains to be examined.

OBJECTIVE

This study will test whether the effects of yoga on CLBP (improved pain severity and interference) are mediated by improved ER, the extent to which effects are related to specific aspects of ER, and the role of pain sensitization as a mediator or moderator of effects. In this study, pain sensitization will be assessed by quantitative sensory testing and gene expression profiles to examine whether pain sensitization moderates yoga's effects on pain or whether yoga and ER abilities reduce pain sensitization, leading to decreased pain severity and interference.

METHODS

For this 2-arm parallel group blinded randomized controlled trial, we will enroll 204 adults with CLBP who will be randomized to receive the yoga (n=102) or a control stretching and strengthening (n=102) intervention, which are delivered via web-based synchronous biweekly 75-minute sessions over 12 weeks. Participants are encouraged to practice postures or exercises for 25 minutes on other days using accessible prerecorded practice videos that are sent to participants digitally. Participants will be assessed at 5 time points: baseline, midintervention (6 weeks), postintervention (12 weeks), and 3- and 6-month follow-ups. Assessments of ER, pain severity and interference, pain sensitivity including somatosensory and gene expression profiles, and physical strength and flexibility will be conducted at each visit. The fidelity of the interventions is assessed using a manualized checklist to evaluate recorded group sessions to ensure consistent instructor delivery.

RESULTS

The primary outcome will be the mean change in pain severity as measured by the Brief Pain Inventory-Short Form at 12 weeks. The primary mechanism of action is ER measured by change in the Difficulties in Emotion Regulation Scale total score. Secondary outcomes include pain sensitivity, physical strength and flexibility, pain interference, and quality of life. A mediation path analysis and series of moderated mediation path analyses will be conducted to test the study hypotheses. As of January 2024, we have enrolled 138 participants. We expect the study to be completed by May 2025.

CONCLUSIONS

The study will provide important data for evaluating whether improvements in ER are responsible for reduced pain perception and pain sensitivity as well as increased quality of life in the context of chronic pain. The study findings have important implications for determining the mechanism of action for yoga and possibly other mind-body interventions as nonpharmacological therapies for pain management. The results of the study will inform the content, delivery, and measures for intervention trials involving yoga as a modality for relieving pain and improving function.

TRIAL REGISTRATION

ClinicalTrials.gov NCT04678297; https://clinicaltrials.gov/study/NCT04678297.

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)

DERR1-10.2196/56016.

[Evidence-based interventions to treat chronic low back pain: treatment selection for a personalized medicine approach : German version]

INTRODUCTION

Chronic low back pain (cLBP) is highly prevalent in the United States and globally, resulting in functional impairment and lowered quality of life. While many treatments are available for cLBP, clinicians have little information about which specific treatment(s) will work best for individual patients or subgroups of patients. The Back Pain Research Consortium, part of the National Institutes of Health Helping to End Addiction Long-termSM (HEAL) Initiative, will conduct a collaborative clinical trial, which seeks to develop a personalized medicine algorithm to optimize patient and provider treatment selection for patients with cLBP.

OBJECTIVE

The primary objective of this article is to provide an update on evidence-based cLBP interventions and describe the process of reviewing and selecting interventions for inclusion in the clinical trial.

METHODS

A working group of cLBP experts reviewed and selected interventions for inclusion in the clinical trial. The primary evaluation measures were strength of evidence and magnitude of treatment effect. When available in the literature, duration of effect, onset time, carryover effect, multimodal efficacy, responder subgroups, and evidence for the mechanism of treatment effect or biomarkers were considered.

CONCLUSION

The working group selected 4 leading, evidence-based treatments for cLBP to be tested in the clinical trial and for use in routine clinical treatment. These treatments include (1) duloxetine, (2) acceptance and commitment therapy, (3) a classification-based exercise and manual therapy intervention, and (4) a self-management approach. These interventions each had a moderate to high level of evidence to support a therapeutic effect and were from different therapeutic classes.

Exploring the Effectiveness of Hatha Yoga as a Complementary Treatment for Adolescent Idiopathic Scoliosis: Clinical Effect and Future Research Directions

Adolescent idiopathic scoliosis (AIS) is a common spinal deformity that primarily affects adolescents during the key period of growth and development. While traditional treatment methods often involve bracing or surgery, Hatha yoga, a millennia-old practice rooted in Indian tradition, has emerged as a complementary option for AIS cases. This paper explores the potential benefits of Hatha yoga for adolescents with AIS. It also discusses the limitations of existing research, such as the lack of large-scale randomized controlled trials (RCTs), varying yoga protocols, and challenges in blinding participants and researchers. To address these limitations, I propose future research directions, including conducting large-scale RCTs, long-term follow-up studies, standardized yoga protocols, and assessing safety concerns. I also highlight the need for tailored interventions and comparative effectiveness studies to better understand the potential of Hatha yoga in the holistic treatment of AIS in adolescents.

[Yoga as an intervention for chronic pain]

The use of yoga, especially as an intervention for chronic pain, is increasing worldwide. Available data on chronic low back pain, within limits also for chronic neck pain and certain types of headache, show statistically significant positive effects related to pain intensity and pain-related impairments. The data provide evidence that yoga is at least equal in efficacy and safety to other exercise interventions as well as individualized physical therapy. The dose of the intervention seems to be of secondary importance, but the establishment of a long-term independent practice after initial supervision seems to be essential; however, for other pain disorders there is still a need for research.

Lessons From India: A Narrative Review of Integrating Yoga Within the US Healthcare System

The ancient practice of yoga has gained worldwide popularity as a way for people to improve their overall health and well-being. This manuscript reviews and examines the history of yoga, its physical and mental health benefits, its incorporation into the Indian healthcare system, and the public perception of yoga in India. Many initiatives for yoga exist, including promoting research on yoga, providing education and information on its benefits, and developing evidence-based standardized yoga therapy guidelines. With this in mind, this narrative review article explores the potential benefits of incorporating yoga into the United States (US) healthcare system and the possible challenges of doing so. It also provides valuable insights for policymakers and healthcare professionals.

Group Acupuncture Therapy With Yoga Therapy for Chronic Neck, Low Back, and Osteoarthritis Pain in Safety Net Settings for an Underserved Population: A Feasibility Pilot Study

Background

Acupuncture and yoga have both been shown to be effective in chronic pain. Underrepresented populations have poorer pain outcomes with less access to effective pain care.

Objective

To assess the feasibility of bundling group acupuncture with yoga therapy for chronic neck, back or osteoarthritis pain in safety net settings.

Methods

This was a feasibility pilot in Bronx and Harlem primary care community health centers. Participants with chronic neck, back or osteoarthritis pain received acupuncture and yoga therapy over a 10-week period. Participants received 10 weekly acupuncture treatments in group setting; with Yoga therapy sessions beginning immediately following the 3rd session. Primary outcome was pain interference and pain intensity on the Brief Pain Inventory (BPI); Outcomes were measured at baseline, 10-week close of intervention, and 24-week follow-up.

Results

93 patients were determined to be eligible and completed the baseline interview. The majority of participants were non-White and Medicaid recipients. 78 (84%) completed the intervention and 10-week survey, and 58 (62%) completed the 24-week post intervention survey. Participants received an average number of 6.5 acupuncture sessions (out of a possible 10), and 4 yoga sessions (out of a possible 8) over the 10-week intervention. Patients showed statistically significant improvements in pain at the close of the intervention and at a somewhat lesser rate, at 24-weeks post intervention. Challenges included telephone outreach and site coordination integrating acupuncture with yoga therapy. The trial also had to be stopped early due to the COVID-19 pandemic.

Conclusions

Bundling acupuncture therapy and yoga therapy is feasible for an underrepresented population with chronic pain in urban community health centers with preliminary indications of acceptability and benefit to participants.

Research study on the effects of multi-component exercise on older adults with chronic conditions

BACKGROUND

Multicomponent exercises involving eccentric contraction (ECC) exercise, chair yoga (CY) and tai chi (TC) are practiced extensively to treat older adults with chronic conditions. The study investigated the effect of CY and TC performance after various intensity of ECC exercise induced muscle pain, delayed onset of muscle sores (DOMS), and strength in sedentary older adults.

METHODS

Nine sedentary older adults with chronic condition(s) aged between 60 and 90 performed CY and TC after ECC exercise protocol for 9 weeks. The medical preprotocol, ECC exercise, CY, and TC performance, subjective (health activities of daily living [ADL] difficulty scale; Visual Analog Scale [VAS], and DOMS), objective (pressure pain threshold [PPT]), and medical postprotocol assessments were carried out and compared the physical status before and after the protocol.

RESULTS

Our results show that functional limitations, DOMS, VAS, and PPT levels were improved in the CY and TC performed weeks 3, 4, 7, and 8 compared to ECC exercise weeks 2 and 6. The manual muscle testing (MMT), active range of motion (AROM), and maximal voluntary isometric contraction (MVIC) were improved and showed significant differences on the weak muscle groups. The mean Tinetti balance and gait score, and general endurance showed significant difference.

CONCLUSIONS

Our findings have important implications for clinical exercise prescription as low perceived CY and TC, and ECC exercise might suit well for older adults with chronic conditions. Performing multicomponent exercises can help to reduce the risk of injury from falls and prevent age-related mobility, balance, and physical function decline in older adults.

Impact of workplace yoga on pain measures, mental health, sleep quality, and quality of life in female teachers with chronic musculoskeletal pain: A randomized controlled study

BACKGROUND

Chronic pain conditions such as low back pain, knee pain and cervical pain are highly prevalent among female teachers. Chronic pain significantly affects the mental health, sleep and quality of life among teachers.

OBJECTIVE

This study is intended to investigate the impact of a workplace yoga intervention on musculoskeletal pain, anxiety, depression, sleep, and quality of life (QoL) among female teachers who had chronic musculoskeletal pain.

METHOD

Fifty female teachers aged between 25-55 years with chronic musculoskeletal pain were randomized to either the yoga group (n = 25) or the control group (n = 25). The yoga group received a 60-minute structured Integrated Yoga intervention (IY) four days a week for six consecutive weeks at school. The control group received no intervention.

OUTCOME MEASURES

Pain intensity, anxiety, depression, stress, fatigue, self-compassion, sleep quality, and quality of life were assessed at the baseline and six weeks.

RESULTS

A significant (p < 0.05) reduction in pain intensity and pain disability in the yoga group was observed after 6-week compared to baseline. Anxiety, depression, stress, sleep scores and fatigues also improved in the yoga group after six weeks. The control group showed no change. Post score comparison showed a significant difference between the groups for all the measures.

CONCLUSION

Workplace yoga intervention is found to be effective in improving pain, pain disability, mental health, sleep quality among female teachers with chronic musculoskeletal pain. This study strongly recommends yoga for the prevention of work-related health issues and for the promotion of wellbeing among teachers.

Yoga for chronic non-specific low back pain

BACKGROUND

Non-specific low back pain is a common, potentially disabling condition usually treated with self-care and non-prescription medication. For chronic low back pain, current guidelines recommend exercise therapy. Yoga is a mind-body exercise sometimes used for non-specific low back pain.

OBJECTIVES

To evaluate the benefits and harms of yoga for treating chronic non-specific low back pain in adults compared to sham yoga, no specific treatment, a minimal intervention (e.g. education), or another active treatment, focusing on pain, function, quality of life, and adverse events.

SEARCH METHODS

We used standard, extensive Cochrane search methods. The latest search date was 31 August 2021 without language or publication status restrictions.

SELECTION CRITERIA

We included randomized controlled trials of yoga compared to sham yoga, no intervention, any other intervention and yoga added to other therapies.

DATA COLLECTION AND ANALYSIS

We followed standard Cochrane methods. Our major outcomes were 1. back-specific function, 2. pain, 3. clinical improvement, 4. mental and physical quality of life, 5. depression, and 6.

ADVERSE EVENTS

Our minor outcome was 1. work disability. We used GRADE to assess certainty of evidence for the major outcomes.

MAIN RESULTS

We included 21 trials (2223 participants) from the USA, India, the UK, Croatia, Germany, Sweden, and Turkey. Participants were recruited from both clinical and community settings. Most were women in their 40s or 50s. Most trials used iyengar, hatha, or viniyoga yoga. Trials compared yoga to a non-exercise control including waiting list, usual care, or education (10 trials); back-focused exercise such as physical therapy (five trials); both exercise and non-exercise controls (four trials); both non-exercise and another mind-body exercise (qigong) (one trial); and yoga plus exercise to exercise alone (one trial). One trial comparing yoga to exercise was an intensive residential one-week program, and we analyzed this trial separately. All trials were at high risk of performance and detection bias because participants and providers were not blinded to treatment, and outcomes were self-assessed. We found no trials comparing yoga to sham yoga. Low-certainty evidence from 11 trials showed that there may be a small clinically unimportant improvement in back-specific function with yoga (mean difference [MD] -1.69, 95% confidence interval [CI] -2.73 to -0.65 on the 0- to 24-point Roland-Morris Disability Questionnaire [RMDQ], lower = better, minimal clinically important difference [MCID] 5 points; 1155 participants) and moderate-certainty evidence from nine trials showed a clinically unimportant improvement in pain (MD -4.53, 95% CI -6.61 to -2.46 on a 0 to 100 scale, 0 no pain, MCID 15 points; 946 participants) compared to no exercise at three months. Low-certainty evidence from four trials showed that there may be a clinical improvement with yoga (risk ratio [RR] 2.33, 95% CI 1.46 to 3.71; assessed as participant rating that back pain was improved or resolved; 353 participants). Moderate-certainty evidence from six trials showed that there is probably a small improvement in physical and mental quality of life (physical: MD 1.80, 95% CI 0.27 to 3.33 on the 36-item Short Form [SF-36] physical health scale, higher = better; mental: MD 2.38, 95% CI 0.60 to 4.17 on the SF-36 mental health scale, higher = better; both 686 participants). Low-certainty evidence from three trials showed little to no improvement in depression (MD -1.25, 95% CI -2.90 to 0.46 on the Beck Depression Inventory, lower = better; 241 participants). There was low-certainty evidence from eight trials that yoga increased the risk of adverse events, primarily increased back pain, at six to 12 months (RR 4.76, 95% CI 2.08 to 10.89; 43/1000 with yoga and 9/1000 with no exercise; 1037 participants). For yoga compared to back-focused exercise controls (8 trials, 912 participants) at three months, we found moderate-certainty evidence from four trials for little or no difference in back-specific function (MD -0.38, 95% CI -1.33 to 0.62 on the RMDQ, lower = better; 575 participants) and very low-certainty evidence from two trials for little or no difference in pain (MD 2.68, 95% CI -2.01 to 7.36 on a 0 to 100 scale, lower = better; 326 participants). We found very low-certainty evidence from three trials for no difference in clinical improvement assessed as participant rating that back pain was improved or resolved (RR 0.97, 95% CI 0.72 to 1.31; 433 participants) and very low-certainty evidence from one trial for little or no difference in physical and mental quality of life (physical: MD 1.30, 95% CI -0.95 to 3.55 on the SF-36 physical health scale, higher = better; mental: MD 1.90, 95% CI -1.17 to 4.97 on the SF-36 mental health scale, higher = better; both 237 participants). No studies reported depression. Low-certainty evidence from five trials showed that there was little or no difference between yoga and exercise in the risk of adverse events at six to 12 months (RR 0.93, 95% CI 0.56 to 1.53; 84/1000 with yoga and 91/1000 with non-yoga exercise; 640 participants).

AUTHORS' CONCLUSIONS

There is low- to moderate-certainty evidence that yoga compared to no exercise results in small and clinically unimportant improvements in back-related function and pain. There is probably little or no difference between yoga and other back-related exercise for back-related function at three months, although it remains uncertain whether there is any difference between yoga and other exercise for pain and quality of life. Yoga is associated with more adverse events than no exercise, but may have the same risk of adverse events as other exercise. In light of these results, decisions to use yoga instead of no exercise or another exercise may depend on availability, cost, and participant or provider preference. Since all studies were unblinded and at high risk of performance and detection bias, it is unlikely that blinded comparisons would find a clinically important benefit.

Tai Chi for spatiotemporal gait features and dynamic balancing capacity in elderly female patients with non-specific low back pain: A six-week randomized controlled trial

BACKGROUND

Non-specific low back pain (NS-LBP) is a serious public health problem. Tai Chi is promising in reducing the risk of falls and alleviating symptoms in this population.

OBJECTIVE

To investigate the effect of Tai Chi on gait and dynamic balance in elderly women with NS-LBP.

METHODS

20 women (age > 65 yr.) with NS-LBP were randomly assigned to a Tai Chi group (n= 10) or a control group (n= 10). The Tai Chi group practiced Tai Chi exercise 3 times a week for 6 weeks. Each session lasted 60 minutes. Pain, spatiotemporal gait features and dynamic balancing capacity were assessed at 0 and 6 weeks.

RESULTS

Compared to the control group at 6 weeks, the Tai Chi group had a significant decrease in VAS (p= 0.027) and stride width (p= 0.019), significant improvement in gait velocity, stride length (p< 0.001). Regarding dynamic balance capacity, the Tai Chi group had significant improvements in anterior (Left: p= 0.001; Right: p= 0.038), postero-lateral (Left: p< 0.001; Right: p= 0.038), and postero-medial (Left: p= 0.015; Right: p= 0.018).

CONCLUSION

6-week Tai Chi can relieve pain and improve gait and dynamic balance in elderly women with NS-LBP, which suggests Tai Chi could be a promising rehabilitation intervention to reduce the risk of falls in this population.

The effect and mechanism of traditional Chinese exercise for chronic low back pain in middle-aged and elderly patients: A systematic review

Background

Increasing lines of evidence indicate that traditional Chinese exercise (TCE) has potential benefits in improving chronic low back pain (CLBP) symptoms. To assess the clinical efficacy of TCE in the treatment of CLBP, we performed a systematic review of existing randomized controlled trials (RCTs) of CLBP and summarized the neural mechanisms underlying TCE in the treatment of CLBP.

Methods

A systematic search was conducted in four electronic databases: PubMed, Embase, the Cochrane Library, and EBSCO from January 1991 to March 2022. The quality of all included RCTs was evaluated by the Physiotherapy Evidence Database Scale (PEDro). The primary outcomes included pain severity and pain-related disability.

Results

A total of 11 RCTs with 1,256 middle-aged and elderly patients with CLBP were included. The quality of all 11 included RCTs ranged from moderate to high according to PEDro. Results suggested that TCE could considerably reduce pain intensity in patients with CLBP. Overall, most studies did not find any difference in secondary outcomes (quality of life, depression, and sleep quality).

Conclusion

The neurophysiological mechanism of TCE for treating CLBP could be linked to meditation and breathing, posture control, strength and flexibility training, and regulation of pain-related brain networks. Our systematic review showed that TCE appears to be effective in alleviating pain in patients with CLBP.

The Effects of Mind-Body Exercises on Chronic Spinal Pain Outcomes: A Synthesis Based on 72 Meta-Analyses

An umbrella review of systematic reviews with a meta-analysis was developed to summarize the evidence on the effectiveness of qigong, tai chi, and yoga in chronic spinal pain outcomes. The CINAHL, Cochrane Library, Embase, PsycINFO, PubMed and SPORTDiscus databases were searched. Pain, psychological factors, and quality of life (QOL) were the outcomes of interest. The methodological quality of the reviews was evaluated using the AMSTAR-2 tool. The overlap was calculated using the corrected covered area. A total of 72 meta-analyses drawn from 20 systematic reviews were included and often were rated at a critically low quality. The effects of qigong on chronic low back and neck pain (CLBP and CNP, respectively) were inconsistent, although it improved the physical component of QOL after 12 weeks for CNP. Tai chi was superior to the controls in reducing CLBP; no reviews of interest were found on CNP. Yoga was superior to multiple controls in reducing CLBP, but no relevant effects on depression or QOL were found. QOL, anxiety, depression, and general mood improved with yoga for CNP. Inconsistencies arose related to yoga and CNP. Our findings mainly supported the potential effects of yoga and tai chi on pain-related outcomes, psychological factors, and QOL in populations with CLBP and NP. Clinical and methodological considerations were discussed.

A Series of Virtual Interventions for Chronic Lower Back Pain: A Feasibility Pilot Study for a Series of Personalized (N-of-1) Trials

Chronic lower back pain (CLBP) affects 25% of U.S. adults and is associated with high costs due to physician visits and reduced productivity. Research shows that massage and yoga can be effective nonpharmacological treatments for CLBP, but the feasibility, scalability, individual treatment, and adverse-event heterogeneity of these treatments are unknown. The current study evaluated the feasibility and acceptability of a series of personalized (N-of-1) interventions for virtual delivery of massage and yoga or usual-care treatment for CLBP in 57 participants. We hypothesized that this study would provide valuable information about implementing a virtual, personalized platform for randomized controlled trials of personalized (N-of-1) interventions among individuals with CLBP. The study will do so by determining participants' ratings of usability and satisfaction with the virtual, personalized intervention delivery system and, in the long term, identifying ways to integrate these personalized trials into patient care. Of the 57 participants enrolled, two withdrew from the study and were not eligible to receive the primary outcome assessment. Thirty-seven of the remaining 55 participants (67.3%) completed satisfaction surveys comprising the System Usability Scale (SUS) and items assessing satisfaction with the components of the personalized trial. Participants rated the usability of the personalized trial as excellent (average SUS score = 85.8), 95% were satisfied with the personalized trial overall, and 100% stated they would recommend the trial to others. These results suggest that personalized trials of massage and yoga are highly feasible and acceptable to participants with CLBP.

A systematic review of chiropractic care for fall prevention: rationale, state of the evidence, and recommendations for future research

BACKGROUND

Falls in older adults are a significant and growing public health concern. There are multiple risk factors associated with falls that may be addressed within the scope of chiropractic training and licensure. Few attempts have been made to summarize existing evidence on multimodal chiropractic care and fall risk mitigation. Therefore, the broad purpose of this review was to summarize this research to date. BODY: Systematic review was conducted following PRISMA guidelines. Databases searched included PubMed, Embase, Cochrane Library, PEDro, and Index of Chiropractic Literature. Eligible study designs included randomized controlled trials (RCT), prospective non-randomized controlled, observational, and cross-over studies in which multimodal chiropractic care was the primary intervention and changes in gait, balance and/or falls were outcomes. Risk of bias was also assessed using the 8-item Cochrane Collaboration Tool. The original search yielded 889 articles; 21 met final eligibility including 10 RCTs. One study directly measured the frequency of falls (underpowered secondary outcome) while most studies assessed short-term measurements of gait and balance. The overall methodological quality of identified studies and findings were mixed, limiting interpretation regarding the potential impact of chiropractic care on fall risk to qualitative synthesis.

CONCLUSION

Little high-quality research has been published to inform how multimodal chiropractic care can best address and positively influence fall prevention. We propose strategies for building an evidence base to inform the role of multimodal chiropractic care in fall prevention and outline recommendations for future research to fill current evidence gaps.

Summarizing the effects of different exercise types in chronic low back pain - a systematic review of systematic reviews

Background

In chronic LBP (CLBP), guideline-endorsed treatment is to stay active, return to normal activity, and to exercise. Several reviews on various exercise types used in CLBP have been published. We aimed to identify systematic reviews of common exercise types used in CLBP, to appraise their quality, and to summarize and compare their effect on pain and disability.

Methods

We searched the databases OVID MEDLINE, EMBASE, COCHRANE LIBRARY, and WEB OF SCIENCE (Core collection) for systematic reviews and meta-analyses on adults between 18 and 70 years of age suffering from chronic or recurrent LBP for a period of at least 12 weeks, which investigated the effects of exercises on pain and disability. All searches were conducted without language restriction. The search was performed up until 2022–01-26. The included reviews were grouped into nine exercise types: aerobic training, aquatic exercises, motor control exercises (MCE), resistance training, Pilates, sling exercises, traditional Chinese exercises (TCE), walking, and yoga. The study quality was assessed with AMSTAR-2. For each exercise type, a narrative analysis was performed, and the level of evidence for the effects of exercise was assessed through GRADE.

Results

Our database search resulted in 3,475 systematic reviews. Out of the 253 full texts that were screened, we included 45 systematic reviews and meta-analyses. The quality of the included reviews ranged from high to critically low. Due to large heterogeneity, no meta-analyses were performed. We found low-to-moderate evidence of mainly short-term and small beneficial effects on pain and disability for MCE, Pilates, resistance training, TCE, and yoga compared to no or minimal intervention.

Conclusions

Our findings show that the effect of various exercise types used in CLBP on pain and disability varies with no major difference between exercise types. Many of the included systematic reviews were of low-to-moderate quality and based on randomized controlled trials with high risk of bias. The conflicting results seen, undermine the certainty of the results leading to very-low-to-moderate quality of evidence for our results. Future systematic reviews should be of higher quality to minimize waste of resources.

Trial registration

PROSPERO: Reg no 190409 Registration date 01AUG 2020.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12891-022-05722-x.

Application of Virtual Reality Technology in Clinical Practice, Teaching, and Research in Complementary and Alternative Medicine

Background

The application of virtual reality (VR) in clinical settings is growing rapidly, with encouraging results. As VR has been introduced into complementary and alternative medicine (CAM), a systematic review must be undertaken to understand its current status.

Aim

This review aims to evaluate and summarize the current applications of VR in CAM, as well as to explore potential directions for future research and development.

Methods

After a brief description of VR technology, we discuss the past 20 years of clinical VR applications in the medical field. Then, we discuss the theoretical basis of the combination of VR technology and CAM, the research thus far, and practical factors regarding usability, etc., from the following three main aspects: clinical application, teaching, and scientific research. Finally, we summarize and propose hypotheses on the application of VR in CAM and its limitations.

Results

Our review of the theoretical underpinnings and research findings to date leads to the prediction that VR and CAM will have a significant impact on future research and practice.

Conclusion

Although there is still much research needed to advance the science in this area, we strongly believe that VR applications will become indispensable tools in the toolbox of CAM researchers and practitioners and will only grow in relevance and popularity in the era of digital health.

The available evidence on the effectiveness of 10 common approaches to the management of non-specific low back pain: An evidence map

BACKGROUND AND OBJECTIVE

Low back pain is common and remains one of the leading causes of disability globally. This study aimed to develop an evidence map of the quantity of available evidence assessing approaches to manage low back pain, to identify potential redundancies or gaps in the synthesized data, and guide future research focus.

DATABASES AND DATA TREATMENT

MEDLINE, Embase, CENTRAL and CINAHL were searched to March 2022 for systematic reviews assessing the effectiveness of 10 guideline-recommended approaches to manage low back pain. For each management strategy, the number of systematic reviews, date of publication, eligibility criteria and included primary trials were extracted and descriptive data presented.

RESULTS

Substantial evidence, including both systematic reviews and primary trials, was available for each management approach except for patient reassurance. The quantity of available evidence has continued to increase over time. Cochrane reviews have been performed for all 10 treatments, except reassurance of the benign nature of low back pain; however, many of the Cochrane reviews were performed prior to 2015. Substantial heterogeneity in the eligibility criteria between systematic reviews exists; however, some age ranges (children and older adults), clinical settings (emergency), and conditions (radiculopathy) were infrequently assessed.

CONCLUSIONS

Based on systematic reviews, there is a large body of evidence assessing the effectiveness of common approaches to manage low back pain. Justification of the need for further systematic reviews and primary trials should consider the available evidence and is essential to avoid potential research redundancy when investigating effective management of low back pain.

SIGNIFICANCE

Substantial evidence (systematic reviews and primary trials) exists for 10 approaches to manage low back pain. The quantity of available evidence has continued to increase over time. The quantity and large heterogeneity of inclusion criteria in available systematic reviews may influence conflicting recommendations in clinical practice guidelines. Justification of the need for further systematic reviews and primary trials is essential to avoid potential research redundancy.

Harnessing the benefits of yoga for myositis, muscle dystrophies, and other musculoskeletal disorders

The recent global increase in popularity of home-based yoga, an ancient Indian technique practiced for thousands of years, has translated into its use as a complementary therapy for a multitude of ailments. This review aims to examine the published literature regarding the effects of yoga therapy on systemic chronic diseases; in particular on the inflammatory myopathies (IMs) and other muscle disorders.

Despite the fact that the evidence base for yoga in inflammatory myositis is in its infancy, collateral results in other disorders such as muscular dystrophies are promising. A beneficial effect of yoga in chronic pain has been shown alongside an improvement in motor function and muscle strength. Patients with Duchenne muscular dystrophy with respiratory involvement may find improvement in lung function. Elderly patients may experience reduction in falls secondary to an improvement in balance while practicing long-term yoga therapy.

Further benefits are improving disorders of mental health such as depression and anxiety. A reported improvement in overall quality of life further suggests its efficacy in reducing morbidity in patients with chronic diseases, who often suffer co-existent psychological comorbidities.

Are Mind-Body Exercise Beneficial for Treating Pain, Function, and Quality of Life in Middle-Aged and Old People With Chronic Pain? A Systematic Review and Meta-Analysis

Background

Aging is a significant risk factor in chronic pain development with extensive disability and greater health care costs. Mind-body exercise (MBE) has been scientifically proven to affect the pain intensity and physical health.

Objectives

To assess the effects of MBE modes (Tai Chi, yoga, and qigong) for treating chronic pain among middle-aged and old people, compared with nonactive and active treatment, as well as function, quality of life, and adverse events.

Methods

We searched PubMed, Embase, Web of Science, Cochrane Library, China National Knowledge Infrastructure (CNKI), Wanfang Database, and Chinese Scientific Journals Full-Text Database (VIP) till March 2022. No restrictions were chartered within the year and language of publication. We included randomized controlled trials of MBE treatment in middle-aged and elderly people with chronic pain. The overall certainty of evidence was evaluated by using the GRADE approach.

Results

A total of 17 studies (n = 1,332) were included in this review. There was low-certainty evidence indicating that MBE had a moderate effect on reducing pain compared with the nonactive and active control group (standard mean difference (SMD): -0.64, 95% confidence interval (CI): -0.86 to -0.42, P < 0.001). Very-low-certainty evidence showed that the pooled SMD for the functional improvement was -0.75 (95% CI: -1.13 to -0.37, P < 0.001). Low-certainty evidence presented that no influence was observed in physical component summary (SMD: 0.23, 95% CI: -0.16 to 0.62, P = 0.24) and mental component summary (SMD: -0.01, 95% CI -0.39 to 0.36, P = 0.95).

Conclusion

Our results indicated that MBE was an effective treatment for reducing symptoms of middle-aged and elderly people with chronic pain compared with nonactive and active control groups. TC and qigong had obvious benefits for knee osteoarthritis in self-reported function, but the efficacy of chronic low back pain was uncertain. No significant benefit of MBE on quality of life in older adults with chronic pain was found. More high-quality RCTs should be conducted to explore the efficacy and mechanism of MBE on chronic pain in middle-aged and elderly people from various dimensions, such as affective and cognitive dimensions.

Systematic Review Registration

https://www.crd.york.ac.uk/PROSPERO/display_record.php?RecordID=316591, identifier CRD42022316591.

Feasibility of a Combined Neuromodulation and Yoga Intervention for Mild Traumatic Brain Injury and Chronic Pain: Protocol for an Open-label Pilot Trial

BACKGROUND

Mild traumatic brain injury (mTBI) and chronic pain often co-occur and worsen rehabilitation outcomes. There is a need for improved multimodal nonpharmacologic treatments that could improve outcomes for both conditions. Yoga is a promising activity-based intervention for mTBI and chronic pain, and neuromodulation through transcranial magnetic stimulation is a promising noninvasive, nonpharmacological treatment for mTBI and chronic pain. Intermittent theta burst stimulation (iTBS) is a type of patterned, excitatory transcranial magnetic stimulation. iTBS can induce a window of neuroplasticity, making it ideally suited to boost the effects of treatments provided after it. Thus, iTBS may magnify the impacts of subsequently delivered interventions as compared to delivering those interventions alone and accordingly boost their impact on outcomes.

OBJECTIVE

The aim of this study is to (1) develop a combined iTBS+yoga intervention for mTBI and chronic pain, (2) assess the intervention's feasibility and acceptability, and (3) gather preliminary clinical outcome data on quality of life, function, and pain that will guide future studies.

METHODS

This is a mixed methods, pilot, open-labeled, within-subject intervention study. We will enroll 20 US military veteran participants. The combined iTBS+yoga intervention will be provided in small group settings once a week for 6 weeks. The yoga intervention will follow the LoveYourBrain yoga protocol-specifically developed for individuals with TBI. iTBS will be administered immediately prior to the LoveYourBrain yoga session. We will collect preliminary quantitative outcome data before and after the intervention related to quality of life (TBI-quality of life), function (Mayo-Portland Adaptability Index), and pain (Brief Pain Inventory) to inform larger studies. We will collect qualitative data via semistructured interviews focused on intervention acceptability after completion of the intervention.

RESULTS

This study protocol was approved by Edward Hines Jr Veterans Administration Hospital Institutional Review Board (Hines IRB 1573116-4) and was prospectively registered on ClinicalTrials.gov (NCT04517604). This study includes a Food and Drug Administration Investigational Device Exemption (IDE: G200195). A 2-year research plan timeline was developed. As of March 2022, a total of 6 veterans have enrolled in the study. Data collection is ongoing and will be completed by November 2022. We expect the results of this study to be available by October 2024.

CONCLUSIONS

We will be able to provide preliminary evidence of safety, feasibility, and acceptability of a novel combined iTBS and yoga intervention for mTBI and chronic pain-conditions with unmet treatment needs.

TRIAL REGISTRATION

ClinicalTrials.gov NCT04517604; https://www.clinicaltrials.gov/ct2/show/NCT04517604.

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)

DERR1-10.2196/37836.

Development of the CLARIFY (CheckList stAndardising the Reporting of Interventions For Yoga) guidelines: a Delphi study

BACKGROUND

The use of yoga as a therapeutic modality is increasing; however, a lack of transparent intervention reporting is restricting the dissemination and implementation of yoga research into clinical and community practice. The aim of this study was to develop a yoga-specific reporting guideline as an extension to existing reporting guidelines for randomised controlled trials, observational studies and case reports.

METHODS

Recognised international stakeholders in the design and conduct of yoga research were invited to contribute to the electronic Delphi survey. A four-round Delphi was conducted, whereby panellists rated selected items for their importance in the inclusion of yoga reporting guidelines, according to a 5-step Likert scale. A priori consensus for item inclusion was agreement of items as 'Very important' or 'Extremely important' by ≥80% of panellists. Non-consensus items were forwarded to subsequent rounds for re-rating.

RESULTS

53 experts in yoga research from 11 countries, primarily identifying as researchers (50%), allied health professionals (18.8%) and yoga professionals (12.5%), consented to participate in the Delphi. Of these, 48 completed Round 1 (91%), 43 completed Round 2 (81%), 39 completed Round 3 (74%) and 32 completed Round 4 (60%). Panellists reached consensus for inclusion on 21 items, grouped under 10 domains reflective of more generic intervention-based guidelines.

CONCLUSIONS

The consensus-based 21-item CLARIFY (CheckList stAndardising the Reporting of Interventions For Yoga) checklist provides a minimum reporting template for researchers across a range of methodology designs. Use of these yoga-specific guidelines, in conjunction with the CLARIFY explanation and elaboration guidelines, will standardise the minimum level of detail required for transparent yoga intervention, facilitating the replication, dissemination and implementation of yoga research. Ongoing research will assess the uptake and impact of CLARIFY, to ensure these guidelines retain their relevance to the internationally growing field of yoga research.

Chronic low back pain during COVID-19 lockdown: is there a paradox effect?

PURPOSE

The coronavirus 2019 (COVID-19) pandemic led to a compulsory lockdown of 3 months with strict restrictions. The impact of the COVID-19 pandemic has shown broad repercussions on patients with chronic pain; especially for conditions that present a significant emotional participation such as chronic low back pain (cLBP).

METHODS

We performed a prospective study on 50 patients. Pre- and 1-month post-lockdown questionnaires such as: the Impact of Event Scale (IES), the Oswestry Disability Index (ODI), the Roland-Morris questionnaire (RMQ) and the visual analogue scale (VAS) for back and leg pain intensity were collected.

RESULTS

The mean time of the evolution of cLBP was 33.04 months (range 5-120 months). Eighteen (36%) patients improved their cLBP (i-cLBP), whereas for 14 (28%) it was worse (w-cLBP). Cox multivariate proportional hazard model identified that MODIC 1 disc disease [OR 19.93, IC95% (2.81-102.13), p = 0.015] and at-home workouts [OR 18.854, IC95% (1.151-204.9), p = 0.040] were good prognosis factors of the improvement of cLBP while subclinical/mild Covid-19 anxiety (IES score < 26) was a poor prognosis factor in improving cLBP [OR 0.21, IC95% (0.001-0.384), p = 0.009]. Furthermore, pre-lockdown benzodiazepine medication [OR 2.554, IC95% (1.20-9.9), p = 0.002] was a prognosis factor of worse cLBP. In contrast, patients with severe Covid-19 anxiety (IES score > 26) significantly improved their cLBP [OR 0.58, IC95% (0.025-0.834), p = 0.01].

CONCLUSION

Lockdown affected the somatic component of cLBP by decreasing activities and physical measures, whereas the SARS-CoV-2 pandemic spectrum paradoxically improved the psychic and emotional component of cLBP.

Yoga therapy as an adjunct to conventional management of systemic sclerosis: A case series

Systemic sclerosis (SSc) is an autoimmune disorder leading to significant disability and loss of Quality of Life (QoL). Yoga has become popular in recent times for its potential therapeutic benefits. Since there are no scientific reports on the use of Yoga for SSc, we present two female cases (aged 49 and 29 respectively) of limited SSc (duration of illness 4 and 3 years respectively) who underwent Yoga therapy as an adjunct to conventional management in a residential setting for a period of five and four weeks, respectively. During their stay, they underwent a specifically designed Yoga module. After their discharge, they were followed-up for four weeks, during which they were asked to continue practicing Yoga for 1 h every day. Both of them reported a reduction in pain, stiffness, symptom scores, and improved QoL on discharge and at the follow-up compared to the values on admission. Erythrocyte Sedimentation Rate (ESR) and C-Reactive Protein (CRP), as biomarkers of inflammation, reduced on the discharge when compared to the baseline. No adverse events were noted during the stay and the follow-up. Thus, the present case series indicate a possible beneficial role of Yoga as an adjunct therapy to conventional management of SSc. Further studies in the area are warranted to ascertain the efficacy of Yoga for SSc.

Making exercise count: Considerations for the role of exercise in back pain treatment

INTRODUCTION

Chronic low back pain (CLBP) is pain that has persisted for greater than three months. It is common and burdensome and represents a significant proportion of primary health presentations. For the majority of people with CLBP, a specific nociceptive contributor cannot be reliably identified, and the pain is categorised as 'non-specific'. Exercise therapy is recommended by international clinical guidelines as a first-line treatment for non-specific CLBP.

AIM

This comprehensive review aims to synthesise and appraise the current research to provide practical, evidence-based guidance concerning exercise prescription for non-specific CLBP. We discuss detailed initial assessment and being informed by patient preferences, values, expectations, competencies and goals.

METHODS

We searched the Cochrane Database of Systematic Reviews, PubMed and the Physiotherapy Evidence Database (PEDro) using broad search terms from January 2000 to March 2021, to identify the most recent clinical practice guidelines, systematic reviews and randomised controlled trials on exercise for CLBP.

RESULTS/DISCUSSION

Systematic reviews show exercise is effective for small, short-term reductions in pain and disability, when compared with placebo, usual care, or waiting list control, and serious adverse events are rare. A range of individualised or group-based exercise modalities have been demonstrated as effective in reducing pain and disability. Despite this consensus, controversies and significant challenges remain.

CONCLUSION

To promote recovery, sustainable outcomes and self-management, exercise can be coupled with education strategies, as well as interventions that enhance adherence, motivation and patient self-efficacy. Clinicians might benefit from intentionally considering their own knowledge and competencies, potential harms of exercise and costs to the patient. This comprehensive review provides evidence-based practical guidance to health professionals who prescribe exercise for people with non-specific CLBP.

A randomized controlled trial to evaluate a behavioral economic strategy for improving mobility in veterans with chronic pain

Rates of chronic pain and daily opioid use are higher among veterans relative to civilian populations. Increasing physical activity can reduce pain severity and decrease opioid use among patients with chronic pain. Behavioral economic strategies can improve physical activity levels but have been undertested in veterans with chronic pain. The objective of this study was to evaluate if a financial incentive combined with a loss aversion component-a "regret lottery" in which veterans could win money if they met a set goal or told how much they could have won had they met their goal-would increase physical activity levels among veterans with chronic pain. A 12-week single-blinded randomized controlled trial (ClinicalTrials.gov: NCT04013529) was designed. Veterans with chronic pain (N = 40) receiving care at a specialty pain clinic were eligible for participation, and were randomly assigned (1:1) to either (a) activity trackers and daily text message reminders to increase physical activity ("control arm"), or (b) the same plus a weekly regret lottery ("intervention arm"). For those in the intervention arm, participants who met their activity goal, had a chance to win a small ($30) or large ($100) gift card incentive; those who did not meet their goals were informed of what they would have won had they met their goal. The primary outcome, physical activity, was measured using self-reported physical activity and step counts using activity trackers. Secondary outcomes included changes in physical function, chronic pain severity, depression and opioid use. The sample was primarily white, male and disabled, with an average age of 57 years. No between-arm differences were noted for physical activity, physical function, chronic pain severity, depression or opioid use. Regret lottery-based approaches may be ineffective at increasing physical activity levels in veterans with chronic pain. Trial Registry: NCT04013529.

Some types of exercise are more effective than others in people with chronic low back pain: a network meta-analysis

QUESTION

What are the effects of specific types of exercise treatments on pain intensity and functional limitation outcomes for adults with chronic low back pain?

DESIGN

Systematic review with network meta-analysis of randomised controlled trials.

PARTICIPANTS

Adults with non-specific low back pain for ≥ 12 weeks.

INTERVENTION

Exercise treatments prescribed or planned by a health professional that involved conducting specific activities, postures and/or movements with a goal to improve low back pain outcomes.

OUTCOME MEASURES

Pain intensity (eg, visual analogue scale or numerical rating scale) and back-related functional limitations (eg, Roland Morris Disability Questionnaire or Oswestry Disability Index), each standardised to range from 0 to 100.

RESULTS

This review included 217 randomised controlled trials with 20,969 participants and 507 treatment groups. Most exercise types were more effective than minimal treatment for pain and functional limitation outcomes. Network meta-analysis results were compatible with moderate to clinically important treatment effects for Pilates, McKenzie therapy, and functional restoration (pain only) and flexibility exercises (function only) compared with minimal treatment, other effective treatments and other exercise types. The estimated mean differences for these exercise types compared with minimal treatment ranged from -15 to -19 for pain and from -10 to -12 for functional limitation.

CONCLUSION

This review found evidence that Pilates, McKenzie therapy and functional restoration were more effective than other types of exercise treatment for reducing pain intensity and functional limitations. Nevertheless, people with chronic low back pain should be encouraged to perform the exercise that they enjoy to promote adherence.

REGISTRATION

DOI:10.1002/14651858.CD009790.

Exercise therapy for chronic low back pain

BACKGROUND

Low back pain has been the leading cause of disability globally for at least the past three decades and results in enormous direct healthcare and lost productivity costs.

OBJECTIVES

The primary objective of this systematic review is to assess the impact of exercise treatment on pain and functional limitations in adults with chronic non-specific low back pain compared to no treatment, usual care, placebo and other conservative treatments.

SEARCH METHODS

We searched CENTRAL (which includes the Cochrane Back and Neck trials register), MEDLINE, Embase, CINAHL, PsycINFO, PEDro, SPORTDiscus, and trials registries (ClinicalTrials.gov and World Health Organization International Clinical Trials Registry Platform), and conducted citation searching of relevant systematic reviews to identify additional studies. The review includes data for trials identified in searches up to 27 April 2018. All eligible trials have been identified through searches to 7 December 2020, but have not yet been extracted; these trials will be integrated in the next update.

SELECTION CRITERIA

We included randomised controlled trials that assessed exercise treatment compared to no treatment, usual care, placebo or other conservative treatment on the outcomes of pain or functional limitations for a population of adult participants with chronic non-specific low back pain of more than 12 weeks' duration.

DATA COLLECTION AND ANALYSIS

Two authors screened and assessed studies independently, with consensus. We extracted outcome data using electronic databases; pain and functional limitations outcomes were re-scaled to 0 to 100 points for meta-analyses where 0 is no pain or functional limitations. We assessed risk of bias using the Cochrane risk of bias (RoB) tool and used GRADE to evaluate the overall certainty of the evidence. When required, we contacted study authors to obtain missing data. To interpret meta-analysis results, we considered a 15-point difference in pain and a 10-point difference in functional limitations outcomes to be clinically important for the primary comparison of exercise versus no treatment, usual care or placebo.

MAIN RESULTS

We included 249 trials of exercise treatment, including studies conducted in Europe (122 studies), Asia (38 studies), North America (33 studies), and the Middle East (24 studies). Sixty-one per cent of studies (151 trials) examined the effectiveness of two or more different types of exercise treatment, and 57% (142 trials) compared exercise treatment to a non-exercise comparison treatment. Study participants had a mean age of 43.7 years and, on average, 59% of study populations were female. Most of the trials were judged to be at risk of bias, including 79% at risk of performance bias due to difficulty blinding exercise treatments. We found moderate-certainty evidence that exercise treatment is more effective for treatment of chronic low back pain compared to no treatment, usual care or placebo comparisons for pain outcomes at earliest follow-up (MD -15.2, 95% CI -18.3 to -12.2), a clinically important difference. Certainty of evidence was downgraded mainly due to heterogeneity. For the same comparison, there was moderate-certainty evidence for functional limitations outcomes (MD -6.8 (95% CI -8.3 to -5.3); this finding did not meet our prespecified threshold for minimal clinically important difference. Certainty of evidence was downgraded mainly due to some evidence of publication bias.  Compared to all other investigated conservative treatments, exercise treatment was found to have improved pain (MD -9.1, 95% CI -12.6 to -5.6) and functional limitations outcomes (MD -4.1, 95% CI -6.0 to -2.2). These effects did not meet our prespecified threshold for clinically important difference. Subgroup analysis of pain outcomes suggested that exercise treatment is probably more effective than education alone (MD -12.2, 95% CI -19.4 to -5.0) or non-exercise physical therapy (MD -10.4, 95% CI -15.2 to -5.6), but with no differences observed for manual therapy (MD 1.0, 95% CI -3.1 to 5.1). In studies that reported adverse effects (86 studies), one or more adverse effects were reported in 37 of 112 exercise groups (33%) and 12 of 42 comparison groups (29%). Twelve included studies reported measuring adverse effects in a systematic way, with a median of 0.14 (IQR 0.01 to 0.57) per participant in the exercise groups (mostly minor harms, e.g. muscle soreness), and 0.12 (IQR 0.02 to 0.32) in comparison groups.

AUTHORS' CONCLUSIONS

We found moderate-certainty evidence that exercise is probably effective for treatment of chronic low back pain compared to no treatment, usual care or placebo for pain. The observed treatment effect for the exercise compared to no treatment, usual care or placebo comparisons is small for functional limitations, not meeting our threshold for minimal clinically important difference. We also found exercise to have improved pain (low-certainty evidence) and functional limitations outcomes (moderate-certainty evidence) compared to other conservative treatments; however, these effects were small and not clinically important when considering all comparisons together. Subgroup analysis suggested that exercise treatment is probably more effective than advice or education alone, or electrotherapy, but with no differences observed for manual therapy treatments.

Yoga for chronic chemotherapy-induced peripheral neuropathy pain: a pilot, randomized controlled trial

PURPOSE

To determine the feasibility of implementing a yoga intervention for cancer survivors with chronic CIPN pain, as well as the impact of the intervention on patient-reported outcomes.

METHODS

Cancer survivors with chronic CIPN pain were recruited from the breast, gastrointestinal, and gynecological oncology centers at Dana-Farber Cancer Institute. Participants were randomized (2:1) to receive an 8-week yoga intervention or usual care. After 21/50 of participants were enrolled, the COVID-19 pandemic required the yoga intervention to be delivered virtually (i.e., Zoom). Pre- and post-intervention, participants self-reported CIPN and co-occurring symptom severity. Adherence to the intervention was defined as practicing ≥ 12 yoga sessions over the 8-week intervention period. Changes in patient-reported outcomes between groups were compared using Wilcoxon's rank-sum tests.

RESULTS

Participants (n = 28 yoga, n = 16 control) were mainly female (96%) and diagnosed with stage III/IV disease (66%). Overall, 19/28 (67.8%) of yoga group participants were adherent to the yoga protocol. Yoga group participants experienced significant within-group improvements in all patient-reported outcomes, including worst CIPN pain (median change =  - 1.7, p < 0.0001) and sensory CIPN (median change =  - 14.8, p < 0.0001), but only improvements in fatigue (p = 0.05) and depression (p = 0.04) were significant compared to the control. There were no differences (p > 0.05) in changes in patient-reported outcomes between in-person (n = 6) or virtual (n = 15) yoga group participants.

CONCLUSIONS

Yoga is a feasible non-pharmacological modality for cancer survivors with CIPN, but more information is needed regarding its impact on CIPN and other symptoms.

TRIAL REGISTRATION

ClinicalTrials.gov Identifier: NCT03824860 IMPLICATIONS FOR CANCER SURVIVORS: Oncology clinicians may consider referring cancer survivors to yoga for chronic CIPN pain, but yoga cannot be currently recommended as an efficacious treatment.

Dynamic evaluation of the contractile function of lumbodorsal muscles during locust pose in yoga by real-time ultrasound

Background and Purpose

Chronic low back pain (CLBP), which has a close relationship with lumbar muscle degeneration, can be effectively treated by exercise therapy, and yoga has been widely accepted by clinicians and patients with CLBP. The purpose of this study was to observe the changes in the thickness of lumbodorsal muscles that occur during locust pose in yoga and how these changes occur. From the changes in muscle thickness that occur in the locust pose, the contractile function of lumbodorsal muscles can be evaluated.

Methods

Fifty-two healthy volunteers (from May 2019 to August 2019, age from 28 to 68 years, 23 males and 29 females (age: 40 ± 8 years; weight: 68.3 ± 5.2 kg; height: 170.2 ± 13.1 cm) were recruited, and lumbodorsal muscle, including the multifidus, longissimus, iliocostalis, and quadratus lumborum, ultrasonic examinations were carried out in the relaxed and contracted states. The changes in the thickness of the lumbodorsal muscles in the relaxed and contracted states were dynamically observed by real-time ultrasound when subjects were performing the locust yoga pose. Then, the thicknesses of the muscles during the two states were measured to calculate the ratio of contraction of each muscle and determine the statistical significance of the change in thickness of each muscle.

Results

The mean thickness of the left multifidus in the relaxed state was 1.32 ± 0.27 cm (95 % CI: 1.24 ~ 1.39), that in the contracted state was 1.60 ± 0.30 cm (95 % CI: 1.52 ~ 1.69) (obviously different between the relaxed and contracted states, P < 0.001), and those in the corresponding right side were 1.37 ± 0.31 cm (95 % CI: 1.29 ~ 2.46) and 1.68 ± 0.38 cm (95 % CI: 1.58 ~ 1.79) (P < 0.001), respectively. The mean thickness of the left quadratus lumborum in the relaxed state was 1.38 ± 0.32 cm (95 % CI: 1.29 ~ 1.47), that in the contracted state was 1.62 ± 0.40 cm (95 % CI: 1.50 ~ 1.73) (P = 0.001), and those in the corresponding right side were 1.30 ± 0.32 cm (95 % CI: 1.21 ~ 1.39) and 1.55 ± 0.41 cm (95 % CI: 1.44 ~ 1.67) (P = 0.001), respectively. The mean thickness of the left longissimus in the relaxed was 2.33 ± 0.51 cm (95 % CI: 2.19 ~ 2.47), that in the contracted state was 3.20 ± 0.61 cm (95 % CI: 3.03 ~ 3.37) (P < 0.001), and those in the corresponding right side were 2.34 ± 0.49 cm (95 % CI 2.20 ~ 2.48) and 3.26 ± 0.68 cm (95 % CI 3.07 ~ 3.45) (P < 0.001), respectively. The mean thickness of the left iliocostalis in the relaxed state was 1.88 ± 0.41 cm (95 % CI: 1.76 ~ 1.99), that in the contracted state was 2.34 ± 0.49 cm (95 % CI: 2.00 ~ 2.47) (P < 0.001), and those in the corresponding right side were 1.98 ± 0.40 cm (95 % CI: 1.87 ~ 2.09) and 2.44 ± 0.56 cm (95 % CI: 2.29 ~ 2.60) (P < 0.001), respectively. The mean contracted state/resting state (C/R) of the longissimus was 1.39 ± 0.14 on the left and 1.40 ± 0.16 on the right. The multifidus and iliocostalis had the second highest C/R. The mean C/R of the multifidus was 1.23 ± 0.12 on the left and 1.24 ± 0.15 on the right, and the mean C/R of the iliocostalis was 1.25 ± 0.12 on the left and 1.24 ± 0.14 on the right. The quadratus lumborum had the lowest C/R, and the mean C/R of the quadratus lumborum was 1.17 ± 0.10 on the left and 1.19 ± 0.11 on the right.

Conclusions

Ultrasound can be used to dynamically assess the contractile function of the lumbar muscle in the locust pose of yoga, the C/R ratio can be used to indicate the ability of a muscle to contract, and dynamic ultrasound can guide lumbar exercise and feedback the exercise results. The establishment of this model allowed data regarding the contraction state of the lumbar muscle to be obtained in a normal population, and based on this, future studies can further explore and evaluate the contraction state of the lumbar muscle after yoga exercise in CLBP patients, the effect exercise on lumbar instability and on a patient population after lumbar operation.

Simulation in physiotherapy students for clinical decisions during interaction with people with low back pain: randomised controlled trial

BACKGROUND

Low back pain (LBP) is a condition with a high global prevalence, which is getting health professionals' attention, including physiotherapists as they must have the skills to provide treatment that increases the patient's quality of life. Clinical simulations could be a pedagogic strategy that facilitates adequate training for students to acquire skills to improve their professional reasoning in this clinical situation.

OBJECTIVE

This study sought to determine the effects of clinical simulations with simulated patients (SP) on the physiotherapy students' clinical decision-making within a role-playing (RP) scenario while caring of LBP patients.

METHODS

This experimental study included 42 participants from two Colombian universities, randomized into two groups (SP, n = 21; RP, n = 21). The clinical skill of performing the Objective Structured Clinical Examination (OSCE-LBP) was evaluated while students cared for patients with LBP; after that, a pedagogical method was conducted that included clinical simulation and, finally, the OSCE-LBP was applied again to compare both groups.

RESULTS

Changes occurred in the OSCE-LBP among both groups of students: the scores increased (0.66 and 0.59 in RP and SP, respectively), and neither of the two was superior (p value 0.01; 95%CI - 0.21 to 0.23).

CONCLUSION

Both types of simulation favor decision-making in professional reasoning in physiotherapy students during interactions with individuals with LBP. Trial registration https://clinicaltrials.gov/ct2/show/NCT04428892 Identifying number: NCT04428892. It was retrospectively registered.

Changes in Perceived Stress After Yoga, Physical Therapy, and Education Interventions for Chronic Low Back Pain: A Secondary Analysis of a Randomized Controlled Trial

OBJECTIVE

Perceived stress and musculoskeletal pain are common, especially in low-income populations. Studies evaluating treatments to reduce stress in patients with chronic pain are lacking. We aimed to quantify the effect of two evidence-based interventions for chronic low back pain (cLBP), yoga and physical therapy (PT), on perceived stress in adults with cLBP.

METHODS

We used data from an assessor-blinded, parallel-group randomized controlled trial, which recruited predominantly low-income and racially diverse adults with cLBP. Participants (N = 320) were randomly assigned to 12 weeks of yoga, PT, or back pain education. We compared changes in the 10-item Perceived Stress Scale (PSS-10) from baseline to 12- and 52-week follow-up among yoga and PT participants with those receiving education. Subanalyses were conducted for participants with elevated pre-intervention perceived stress (PSS-10 score ≥17). We conducted sensitivity analyses using various imputation methods to account for potential biases in our estimates due to missing data.

RESULTS

Among 248 participants (mean age = 46.4 years, 80% nonwhite) completing all three surveys, yoga and PT showed greater reductions in PSS-10 scores compared with education at 12 weeks (mean between-group difference = -2.6, 95% confidence interval [CI] = -4.5 to -0.66, and mean between-group difference = -2.4, 95% CI = -4.4 to -0.48, respectively). This effect was stronger among participants with elevated pre-intervention perceived stress. Between-group effects had attenuated by 52 weeks. Results were similar in sensitivity analyses.

CONCLUSIONS

Yoga and PT were more effective than back pain education for reducing perceived stress among low-income adults with cLBP.

Yoga for older adults with multimorbidity (the Gentle Years Yoga Trial): study protocol for a randomised controlled trial

BACKGROUND

Multimorbidity is common in older adults and associated with high levels of illness burden and healthcare expenditure. The evidence base for how to manage older adults with multimorbidity is weak. Yoga might be a useful intervention because it has the potential to improve health-related quality of life, physical functioning, and several medical conditions. The British Wheel of Yoga's Gentle Years Yoga© (GYY) programme was developed specifically for older adults, including those with chronic medical conditions. Data from a pilot trial suggested feasibility of using GYY in this population, but its effectiveness and cost-effectiveness remain uncertain.

METHODS

This is a multi-site, individually randomised, superiority trial with an embedded process evaluation and an economic analysis of cost-effectiveness. The trial will compare an experimental strategy of offering a 12-week GYY programme against a control strategy of no offer in community-dwelling adults aged 65 or over who have multimorbidity, defined as having two or more chronic conditions from a predefined list. The primary outcome is health-related quality of life measured using the EQ-5D-5L, the primary endpoint being the overall difference over 12 months. Both groups will continue to be able to access their usual care from primary, secondary, community, and social services. Participants, care providers, and yoga teachers will not be blinded to the allocated intervention. Outcome measures are primarily self-reported. The analysis will follow intention-to-treat principles.

DISCUSSION

This pragmatic randomised controlled trial will demonstrate if the GYY programme is an effective, cost-effective, and viable addition to the management of older adults with multimorbidity.

TRIAL REGISTRATION

ISRCTN ISRCTN13567538 . Registered on 18 March 2019.

Brain-Derived Neurotrophic Factor and Immune Cells in Osteoarthritis, Chronic Low Back Pain, and Chronic Widespread Pain Patients: Association with Anxiety and Depression

Background and Objectives: Musculoskeletal dysfunction can induce several types of chronic pain syndromes. It is of particular interest to elucidate the pathomechanism of different forms of chronic pain. It is possible that patients who have developed chronic widespread pain (CWP) may endure different pathomechanisms as compared to those who suffer from local pain (osteoarthritis, OA) and regional pain (chronic low back pain, cLBP), especially with regard to pain regulation and its related biomediators. The aim of this study was to determine the differences in pathomechanisms among these patients by measuring pain-related biomediators, particularly brain-derived neurotrophic factor (BDNF). Additionally, subpopulations of immune cells were determined in parallel. Materials and Methods: Patients and healthy subjects (HSs) were recruited (age and gender-matched). BDNF was measured from serum samples of patients and HSs and the data of body composition parameters were recorded. Additionally, both patients and HSs were asked to fill in questionnaires related to pain intensity, anxiety, and depression. Results: Our results highlight that the levels of both free and total BDNF are significantly lower in pain patients compared to HSs, with p values of 0.041 and 0.024, respectively. The number of CD3- CD56bright natural killer (NK) cells shows significant differences between the groups. Comparing all chronic pain patients with HSs reveals a significantly lower number of CD4+ CD8+ T cells (p = 0.031), CD3- CD56bright NK cells (p = 0.049) and CD20+ CD3- cells (p = 0.007). Conclusions: To conclude, it seems that a general conformity between the pathomechanisms of different chronic pain diseases exists, although there are unique findings only in specific chronic pain patients.

Barriers and Facilitators to Implementing Bundled Acupuncture and Yoga Therapy to Treat Chronic Pain in Community Healthcare Settings: A Feasibility Pilot

Objective: To identify factors associated with implementing bundled group acupuncture and yoga therapy (YT) to treat underserved patients with chronic pain in community health center (CHC) settings. This is not an implementation science study, but rather an organized approach for identification of barriers and facilitators to implementing these therapies as a precursor to a future implementation science study. Design: This study was part of a single-arm feasibility trial, which aimed to test the feasibility of bundling GA and YT for chronic pain in CHCs. Treatment outcomes were measured before and after the 10-week intervention period. Implementation feasibility was assessed through weekly research team meetings, weekly yoga provider meetings, monthly acupuncture provider meetings, and weekly provider surveys. Settings: The study was conducted in New York City at two Montefiore Medical Group (MMG) sites in the Bronx, and one Institute for Family Health (IFH) site in Harlem. Subjects: Participants in the feasibility trial were recruited from IFH and MMG sites, and needed to have had lower back, neck, or osteoarthritis pain for >3 months. Implementation stakeholders included the research team, providers of acupuncture and YT, referring providers, and CHC staff. Results: Implementation of these therapies was assessed using the Consolidated Framework for Implementation Research. We identified issues associated with scheduling, treatment fidelity, communication, the three-way disciplinary interaction of acupuncture, yoga, and biomedicine, space adaptation, site-specific logistical and operational requirements, and patient-provider language barriers. Issues varied as to their frequency and resolution difficulty. Conclusions: This feasibility trial identified implementation issues and resolution strategies that could be further explored in future implementation studies. Clinical Trial Registration No.: NCT04296344.

Musculoskeletal Disorders among Italian Dentists and Dental Hygienists

Dental professionals often perform physically and mentally demanding therapeutical procedures. They work maintaining muscular imbalance and asymmetrical positions for a long time. The aim of the study was to describe the prevalence and the factors associated to work-related musculoskeletal disorders (WMSD) among Italian dental professionals and the most affected body regions. A cross-sectional observational study was conducted between March 2019 and February 2020. The Nordic Musculoskeletal questionnaire (NMQ) was implemented with questions related to working habits (dental occupation, working hours per week and per days, years of work) and lifestyle (practiced physical activity, including frequency and duration, mobilization activities, and knowledge of ergonomic guidelines) was used. The-chi square test was carried out to detect any statistically significant difference (p < 0.05). Logistic regression was carried out to detect the most significant factors associated to WMSD occurrence. A total of 284 questionnaires have been used for the analysis. A high proportion of dental professionals (84.6%) were affected by WMSD in the last 12 months. A higher prevalence was found in females (87%) when compared to males (80%). The prevalence of WMSD was correlated to the working hours/day and hour/week, with a higher risk for operators working >5 h/day and >30 h/week. In addition, a high prevalence was found in operators working for 2–5 years after graduation. Most of the surveyed dental professionals practiced physical activity (70.1%) but only a few had satisfactorily knowledge of ergonomic guidelines (12.7%). Interestingly, participants who practiced yoga or stretching as physical activities demonstrated lower WMSD (77%) when compared to other physical activities (84%). We can highlight that generic physical activities have no functional effect on WMSD for dental professionals. The most affected body areas were neck (59.9%), shoulders (43.3%), lumbar region (52.1%), dorsal region (37.7%) and wrists (30.6%). Considering the magnitude of the problem, there is an urgent need to implement the education in ergonomics among dental professionals, that may be achieved by teaching biomechanics, posturology and integrative functional therapies (such as yoga) during the university education and by promoting holistic health of dental operators.

Integrated Meditation and Exercise Therapy: A Randomized Controlled Pilot of a Combined Nonpharmacological Intervention Focused on Reducing Disability and Pain in Patients with Chronic Low Back Pain

OBJECTIVE

This pilot trial examined the effects of a combined intervention of mindfulness meditation followed by aerobic walking exercise compared with a control condition in chronic low back pain patients. We hypothesized that meditation before exercise would reduce disability, pain, and anxiety by increasing mindfulness prior to physical activity compared with an audiobook control group.

PARTICIPANTS

Thirty-eight adults completed either meditation and exercise treatment (MedExT) (n=18) or an audiobook control condition (n=20).

SETTING

Duquesne University Exercise Physiology Laboratory.

DESIGN

A pilot, assessor-blinded, randomized controlled trial.

METHODS

Over a 4-week period, participants in the MedExT group performed 12-17 minutes of guided meditation followed by 30 minutes of moderate-intensity walking exercise 5 days per week. Measures of disability, pain, mindfulness, and anxiety were taken at baseline and postintervention. Pain perception measurements were taken daily.

RESULTS

Compared with the control group, we observed larger improvements in disability in the MedExT intervention, although the changes were modest and not statistically significant (mean between-group difference, -1.24; 95% confidence interval [CI], -3.1 to 0.6). For secondary outcome measures, MedExT increased mindfulness (within-group) from pre-intervention to postintervention (P=0.0141). Additionally, mean ratings of low back pain intensity and unpleasantness significantly improved with time for the MedExT group compared with that of the control group, respectively (intensity P=0.0008; unpleasantness P=0.0022).

CONCLUSION

. Overall, 4 weeks of MedExT produced suggestive between-group trends for disability, significant between-group differences for measures of pain, and significant within-group increases in mindfulness.

Can Yoga or Physical Therapy for Chronic Low Back Pain Improve Depression and Anxiety Among Adults From a Racially Diverse, Low-Income Community? A Secondary Analysis of a Randomized Controlled Trial

OBJECTIVE

To determine and compare the effect of yoga, physical therapy (PT), and education on depressive and anxious symptoms in patients with chronic low back pain (CLBP).

DESIGN

Secondary analysis of a randomized controlled trial.

SETTING

Academic safety net hospital and 7 community health centers.

PARTICIPANTS

A total of 320 adults with CLBP.

INTERVENTION

Yoga classes, PT sessions, or an educational book.

OUTCOME MEASURE

Depression and anxiety were measured using the Patient Health Questionnaire and Generalized Anxiety Disorder 7-item Scale, respectively, at baseline, 12, and 52 weeks. We identified baseline and midtreatment (6-wk) factors associated with clinically meaningful improvements in depressive (≥3 points) or anxious (≥2 points) symptoms at 12 weeks.

RESULTS

Participants (female=64%; mean age, 46.0±10.7 years) were predominantly non-White (82%), low-income (<$30,000/year, 59%), and had not received a college degree (71%). Most participants had mild or worse depressive (60%) and anxious (50%) symptoms. At 12 weeks, yoga and PT participants experienced modest within-group improvements in depressive symptoms (mean difference [MD]=-1.23 [95% CI, -2.18 to -0.28]; MD=-1.01 [95% CI, -2.05 to -0.03], respectively). Compared with the education group, 12-week differences were not statistically significant, although trends favored yoga (MD=-0.71 [95% CI, -2.22 to 0.81]) and PT (MD= -0.32 [95% CI, -1.82 to 1.18]). At 12 weeks, improvements in anxious symptoms were only found in participants who had mild or moderate anxiety at baseline. Independent of treatment arm, participants who had 30% or greater improvement in pain or function midtreatment were more likely to have a clinically meaningful improvement in depressive symptoms (odds ratio [OR], 1.82 [95% CI, 1.03-3.22]; OR, 1.79 [95% CI, 1.06-3.04], respectively).

CONCLUSIONS

In our secondary analysis we found that depression and anxiety, common in this sample of underserved adults with CLBP, may improve modestly with PT and yoga. However, effects were not superior to education. Improvements in pain and function are associated with a decrease in depressive symptoms. More research is needed to optimize the integration of physical and psychological well-being in PT and yoga.

Caregivers of People With Disabilities: A Program to Enhance Wellness Self-Care

Caregivers are a source of support for family members with disabilities. However, caregivers are at risk for caregiver burden, which can erode self-care skills and lead to poor physical and mental health outcomes. Caregiver Wellness Self-Care, developed to address that risk, is a 5-week group program in which participants learn about strategies that cultivate their inner resources, while connecting with others for support. Wellness, self-care, mindfulness, and yoga-based information and practices are taught in the sessions and included in participant handouts. Self-reflection and planning activities with facilitated discussions further support awareness and personal transformation. Designed by and for people providing care to an adult family member with a mental health disorder and a developmental/intellectual disability, the program was piloted three times. The current article describes the development of the program through caregiver involvement, participant and facilitator feedback, and implications for future efforts to build caregiver wellness self-care skills. Implications for nurses are highlighted. [Journal of Psychosocial Nursing and Mental Health Services, 59(5), 25-32.].

Real-World Experiences With Yoga on Cancer-Related Symptoms in Women With Breast Cancer

Purpose

Integrative therapies such as yoga are potential treatments for many psychological and physical symptoms that occur during and/or after treatment for cancer. The purpose of the current study was to evaluate the patient-perceived benefit of yoga for symptoms commonly experienced by breast cancer survivors.

Methods

1,049 breast cancer survivors who had self-reported use of yoga on a follow up survey, in an ongoing prospective Mayo Clinic Breast Disease Registry (MCBDR), received an additional mailed yoga-focused survey asking about the impact of yoga on a variety of symptoms. Differences between pre- and post- scores were assessed using Wilcoxon Signed Rank Test.

Results

802/1,049 (76%) of women who were approached to participate, consented and returned the survey. 507/802 (63%) reported use of yoga during and/or after their cancer diagnosis. The vast majority of respondents (89.4%) reported some symptomatic benefit from yoga. The most common symptoms that prompted the use of yoga were breast/chest wall pain, lymphedema, and anxiety. Only 9% of patients reported that they had been referred to yoga by a medical professional. While the greatest symptom improvement was reported with breast/chest wall pain and anxiety, significant improvement was also perceived in joint pain, muscle pain, fatigue, headache, quality of life, hot flashes, nausea/vomiting, depression, insomnia, lymphedema, and peripheral neuropathy, (all p-values <0.004).

Conclusion

Data supporting the use of yoga for symptom management after cancer are limited and typically focus on mental health. In this study, users of yoga often reported physical benefits as well as mental health benefits. Further prospective studies investigating the efficacy of yoga in survivorship are warranted.

Yoga vs Stretching in Veterans With Chronic Lower Back Pain and the Role of Mindfulness: A Pilot Randomized Controlled Trial

Objective

The purpose of this study was to investigate the feasibility of recruiting, randomizing, enrolling, and collecting outcome data on veteran patients with chronic low back pain (CLBP) who undergo an 8-week, active exercise class with mindfulness (yoga class) and without (stretching class).

Methods

United States veterans with CLBP based on inclusion/exclusion criteria were randomized to 1 of 2 groups. The study design was a pilot randomized controlled trial. Twenty CLBP patients attended a yoga class or stretching class once per week for 8 weeks at the Veterans Affairs Rochester Outpatient Center, Rochester, New York. The following measurements were obtained: recruitment or enrollment data, compliance data to include class attendance and home exercise, and compliance data regarding ability to collect outcome measures at baseline and at completion. Outcome measures included pain (PEG), quality of life (PROMIS Global Health Survey), self-efficacy (2-item questionnaire), fear avoidance belief, catastrophizing, and social engagement in addition to qualitative clinician open-ended questions postintervention.

Results

Forty-five veterans were queried regarding interest in participation. Of these, 34 (76%) met the study's criteria. Twenty (44%) agreed to participate and were consented, randomized, and enrolled in the study. Initial and final outcome measures were obtained for each participant (100%). Forty percent attended more than 80% of the sessions for both yoga and stretching groups.

Conclusion

This pilot study demonstrated feasibility of recruiting, enrolling, and collecting outcome data on CLBP veteran patients participating in yoga and stretching class. The data from this pilot will inform the development of a randomized, comparative effectiveness study of yoga with and without mindfulness in the management of CLBP.

Exercise/physical activity and health outcomes: an overview of Cochrane systematic reviews

BACKGROUND

Sedentary lifestyle is a major risk factor for noncommunicable diseases such as cardiovascular diseases, cancer and diabetes. It has been estimated that approximately 3.2 million deaths each year are attributable to insufficient levels of physical activity. We evaluated the available evidence from Cochrane systematic reviews (CSRs) on the effectiveness of exercise/physical activity for various health outcomes.

METHODS

Overview and meta-analysis. The Cochrane Library was searched from 01.01.2000 to issue 1, 2019. No language restrictions were imposed. Only CSRs of randomised controlled trials (RCTs) were included. Both healthy individuals, those at risk of a disease, and medically compromised patients of any age and gender were eligible. We evaluated any type of exercise or physical activity interventions; against any types of controls; and measuring any type of health-related outcome measures. The AMSTAR-2 tool for assessing the methodological quality of the included studies was utilised.

RESULTS

Hundred and fifty CSRs met the inclusion criteria. There were 54 different conditions. Majority of CSRs were of high methodological quality. Hundred and thirty CSRs employed meta-analytic techniques and 20 did not. Limitations for studies were the most common reasons for downgrading the quality of the evidence. Based on 10 CSRs and 187 RCTs with 27,671 participants, there was a 13% reduction in mortality rates risk ratio (RR) 0.87 [95% confidence intervals (CI) 0.78 to 0.96]; I2 = 26.6%, [prediction interval (PI) 0.70, 1.07], median effect size (MES) = 0.93 [interquartile range (IQR) 0.81, 1.00]. Data from 15 CSRs and 408 RCTs with 32,984 participants showed a small improvement in quality of life (QOL) standardised mean difference (SMD) 0.18 [95% CI 0.08, 0.28]; I2 = 74.3%; PI -0.18, 0.53], MES = 0.20 [IQR 0.07, 0.39]. Subgroup analyses by the type of condition showed that the magnitude of effect size was the largest among patients with mental health conditions.

CONCLUSION

There is a plethora of CSRs evaluating the effectiveness of physical activity/exercise. The evidence suggests that physical activity/exercise reduces mortality rates and improves QOL with minimal or no safety concerns.

TRIAL REGISTRATION

Registered in PROSPERO ( CRD42019120295 ) on 10th January 2019.

Group Acupuncture Therapy With Yoga Therapy for Chronic Neck, Low Back, and Osteoarthritis Pain in Safety Net Setting for an Underserved Population: Design and Rationale for a Feasibility Pilot

Chronic pain is prevalent in the United States, with impact on physical and psychological functioning as well as lost work productivity. Minority and lower socioeconomic populations have increased prevalence of chronic pain with less access to pain care, poorer outcomes, and higher risk of fatal opioid overdose. Acupuncture therapy is effective in treating chronic pain conditions including chronic low back pain, neck pain, shoulder pain, and knee pain from osteoarthritis. Acupuncture therapy, including group acupuncture, is feasible and effective, and specifically so for underserved and diverse populations at risk for health outcome disparities. Acupuncture therapy also encourages patient engagement and activation. As chronic pain improves, there is a natural progression to want and need to increase activity and movement recovery. Diverse movement approaches are important for improving range of motion, maintaining gains, strengthening, and promoting patient engagement and activation. Yoga therapy is an active therapy with proven benefit in musculoskeletal pain disorders and pain associated disability. The aim of this quasi-experimental pilot feasibility trial is to test the bundling of these 2 effective care options for chronic pain, to inform both the design for a larger randomized pragmatic effectiveness trial as well as implementation strategies across underserved settings.

Movement-Based Therapies in Rehabilitation

Movement therapy refers to a broad range of Eastern and Western mindful movement-based practices used to treat the mind, body, and spirit concurrently. Forms of movement practice are universal across human culture and exist in ancient history. Research demonstrates forms of movement therapy, such as dance, existed in the common ancestor shared by humans and chimpanzees, approximately 6 million years ago. Movement-based therapies innately promote health and wellness by encouraging proactive participation in one's own health, creating community support and accountability, and so building a foundation for successful, permanent, positive change.

Low theoretical fidelity hinders the research on health coaching for opioid reduction: A systematic review of randomized controlled trials

Purpose

To systematically review the literature in order to evaluate the effects of health coaching on patients’ reduction of opioid usage and opioid discontinuation. In addition, this systematic review investigated the effects of health coaching on pain intensity, physical function, and quality of life.

Methods

Four electronic databases (PubMed, Embase, Scopus, and PsychINFO) were searched from inception to December 2019. Randomized controlled trials assessing the effects of health coaching interventions in adult patients currently using opioids were included. We considered trials if they included any of the four defined key constructs of health coaching adopted in this review: motivational interviewing, positive psychology, the transtheoretical model, and self-determination theory Independent reviewers screened and selected studies, extracted data, and assessed risk of bias using Revised Cochrane risk-of-bias tool for randomized trials (RoB2) and quality of evidence using Grading, Recommendation, Assessment, Development, and Evaluation (GRADE). The review is registered in the International Prospective Register of Systematic Reviews (PROSPERO) databased as CRD42019136201. It was not possible to perform a meta-analysis due to heterogeneity between included trials.

Results

Eleven studies met our inclusion criteria (n = 4,516 participants). No study assessed all four constructs of health coaching. All eleven studies utilized only one of the constructs, brief motivational interviewing. Thus, we reported our results in terms of motivational interviewing. There is conflicting and very low quality of evidence that brief motivational interviewing may or may not be more effective than education to reduce opioid usage. There is very low quality of evidence that brief motivational interviewing is more effective than educational monthly diaries to reduce opioid use. There is very low to low quality of evidence that brief motivational interviewing is not more effective than no behavioral intervention to reduce opioid use at 6 months follow-up, treatment as usual (TAU) to improve overdose risk behaviors, and TAU to improve physical and psychological health.

Conclusion

There is no direct evidence related to the effect of health coaching on opioid reduction. There is limited, low quality evidence to conclude brief motivational interviewing reduces opioid usage in opioid-dependent patients. Future research should focus on the impact of high theoretical health coaching interventions on opioid usage.

Feasibility of a yoga intervention to decrease pain in older women: a randomized controlled pilot study

BACKGROUND

A significant proportion of older women suffer from chronic pain, which can decrease quality of life. The objective of this pilot randomized study was to evaluate the feasibility of a flow-restorative yoga intervention designed to decrease pain and related outcomes among women aged 60 or older.

METHODS

Flow-restorative yoga classes were held twice weekly for 1 hour and led by a certified yoga instructor. Participants randomized to the intervention group attended the yoga classes for 12 weeks and received supplemental materials for at-home practice. Those randomized to the control group were asked to maintain their normal daily routine. Feasibility was evaluated using recruitment and retention rates, class and home practice adherence rates, and participant satisfaction surveys. Outcome measures (self-reported pain, inflammatory markers, functional fitness, quality of life, resilience, and self-reported physical activity) were assessed at baseline and post-intervention. Paired t-tests or Wilcoxon signed-rank tests were used to examine changes in outcome measures within treatment groups.

RESULTS

Thirty-eight participants were recruited and randomized. Participants were primarily white, college-educated, and higher functioning, despite experiencing various forms of chronic pain. Attendance and retention rates were high (91 and 97%, respectively) and the majority of participants were satisfied with the yoga program (89%) and would recommend it to others (87%). Intervention participants also experienced reductions in pain interference and improvements in energy and social functioning.

CONCLUSIONS

This pilot study provides essential data to inform a full scale randomized trial of flow-restorative yoga for older women with chronic pain. Future studies should emphasize strategies to recruit a more diverse study population, particularly older women at higher risk of disability and functional decline.

TRIAL REGISTRATION

Clinicaltrials.gov , NCT03790098 . Registered 31 December 2018 - Retrospectively registered.

[Integrated care management for older people with chronic diseases in domesticity: evidence from Cochrane reviews]

Hintergrund

Die Anzahl multipel chronisch erkrankter Älterer steigt, und Multimorbidität geht mit hoher Inanspruchnahme von Gesundheitsleistungen einher. Um Selbstständigkeit und Verbleib in der Häuslichkeit zu erhalten, wird zunehmend ein integriertes Versorgungsmanagement eingesetzt. Zur Wirksamkeit in der Zielgruppe der multipel chronisch erkrankten Älteren liegen aber kaum belastbare Daten vor.

Ziel der Arbeit

Bewertung der Wirksamkeit von integriertem Versorgungsmanagement bei Erwachsenen und Abschätzung der Übertragbarkeit auf ältere, multimorbide Personen in Deutschland.

Methoden

Systematische Literaturrecherche in der Cochrane Library mit Einschluss von Cochrane-Reviews (CR) zu (a) den 13 häufigsten Gesundheitsproblemen im Alter, mit (b) Komponenten des integrierten Versorgungsmanagements bei (c) Erwachsenen jeden Alters. Experten schätzten die Übertragbarkeit der eingeschlossenen CR auf multipel chronisch erkrankte Ältere in Deutschland ein.

Ergebnisse

Aus 1412 Treffern wurden 126 CR eingeschlossen. Zur Endpunktkategorie Selbstständigkeit und funktionale Gesundheit zeigten 25 CR klinisch relevante Ergebnisse mit moderater Evidenzqualität. Folgende Interventionskomponenten wurden – unter Berücksichtigung identifizierter Barrieren – als übertragbar eingeschätzt und könnten für ein effektives, indikationsspezifisch integriertes Versorgungsmanagement multipel chronisch erkrankter Älterer herangezogen werden: (1) körperliche Aktivierung, (2) multidisziplinäre Interventionen, (3) das Selbstmanagement verstärkende Interventionen, (4) kognitive Therapieverfahren, (5) telemedizinische Interventionen und (6) Disease-Management-Programme.

Schlussfolgerungen

Die identifizierten Komponenten sollten in versorgungs- und patientennahen randomisierten kontrollierten Studien auf Wirksamkeit bei gebrechlichen Älteren geprüft werden.

Zusatzmaterial online

Zusätzliche Informationen sind in der Online-Version dieses Artikels (10.1007/s00391-020-01796-1) enthalten.