| Abstract|| |
Background: Low-income people are disproportionately affected by chronic back and neck pain. Yoga may be an effective therapy. Aims: This feasibility pilot study evaluated an individualized yoga plan for the treatment of chronic spinal pain. Methods: Participants were recruited from a federally qualified health center in Madison, Wisconsin, USA. Each participant received an individually tailored yoga prescription and practice plan. Pain and quality of life were measured pre and post intervention using the standard 10-cm pain scale and the well-validated EQ-5D-3L, respectively. Qualitative data regarding participants' attitudes and experience were also collected and analyzed. Results: Individuals showed a mean change of −2.4 from pre/post 10-cm pain scale recordings (P = 0.028, 95% confidence interval [CI]: −0.390–−4.477) and a mean increase of 0.26 on the EQ-5D-3L (P = 0.029, 95% CI: 0.04–0.47). The intervention was well-received. Conclusions: An individually tailored yoga program was acceptable to these participants. Pain and quality of life scores appeared to improve.
Keywords: Back pain, low income, neck pain, yoga
|How to cite this article:|
Hampton AR, Temte EG, Barrett BP. Individually tailored yoga for chronic neck or back pain in a low-income population: A pilot study. Int J Yoga 2020;13:70-2
|How to cite this URL:|
Hampton AR, Temte EG, Barrett BP. Individually tailored yoga for chronic neck or back pain in a low-income population: A pilot study. Int J Yoga [serial online] 2020 [cited 2020 Jan 23];13:70-2. Available from: http://www.ijoy.org.in/text.asp?2020/13/1/70/273012
| Introduction|| |
Chronic pain affects 100 million Americans and generates more than $560 billion in health-care costs each year. Chronic spinal pain disproportionately affects people of lower socioeconomic status.
Yoga may be an effective management strategy for the treatment of chronic spinal pain. A 2016 systematic review showed evidence of benefit for yoga in chronic low back-related pain and disability. A 2017 Cochrane review (n = 810) reported evidence for mild-to-moderate benefit from yoga for chronic low back pain and disability, as compared to nonexercise controls. In 2017, Cramer et al. published a meta-analysis of three studies (n = 188) with results favoring yoga for pain intensity and neck-related disability, quality of life, and mood as compared to usual care. However, to date, few studies have been conducted to ascertain the effect of an individually tailored program of yoga based on the preferences, physical capabilities, and pain history specific to the individual for the treatment of chronic pain. Recently, Highland et al. published the promising results of a feasibility trial of an individually tailored program of yoga for veterans with low back pain (n = 68); the group receiving the individually tailored yoga intervention demonstrated improved pain as compared to controls.
This feasibility study was designed to help determine: (1) whether a low-income population finds an individually tailored program of yoga to be an acceptable intervention for the treatment of chronic neck and back pain and (2) whether pain and quality of life assessments suggest a possible benefit. As such, this initial study could inform future research concerning the efficacy of individually tailored yoga for economically disadvantaged people affected by chronic back and neck pain.
| Methods|| |
Participants were recruited from a federally qualified health center in Madison, Wisconsin, USA. Inclusion criteria included age 30–65 years, English or Spanish fluency, and self-reported neck and/or back pain at least 5 days of the week for 3 months or more before enrollment. Exclusion criteria included regular yoga practice in the past 12 months, pregnancy, nonambulatory, known metastatic lesions to bone, history of pathologic fracture, history of back or neck surgery in the past 6 weeks or planned in the next 6 months, psychotic mental health disorder, lack of decisional capacity, and inability to adhere to proposed intervention and follow-up schedule.
During the enrollment period, each participant met individually with the yoga instructor and developed an individualized yoga prescription based on the participant's pattern of pain and mobility. The yoga instructor was also the lead author, Adrienne Hampton, MD, a board-certified family physician and registered yoga teacher at the 500-h level through Yoga Alliance. Each yoga prescription included five simple, beginning asanas, a breath practice, and Savasana. The following is a list of the asanas used in this study: baby cobra, bridge, cat/cow, dead bug, downward-facing dog, front lunge, psoas wake-up, psoas walk, seated twist, side angle, standing side stretch, standing wide-legged forward bend, sumo, supine hamstring stretch, supine leg lifts, supine twist, Uddiyana Bandha wake-up, Warrior I, and Warrior II. The breath practice was the same for all participants. Participants were instructed to focus on feeling the points of contact with floor or chair, relaxing the soft palate, and allowing the full completion of the exhalation before beginning the next inhalation.
After individualized yoga asanas were decided, group yoga practice sessions were held once weekly for 12 weeks. Participants were encouraged to practice at home and attend class each week. Each participant was free to “drop-in” at their convenience and to practice their prescribed yoga program in class, with some individual attention from the yoga teacher and a teaching assistant. We also encouraged home practice of the prescribed yoga program for 20 min daily.
The primary outcome of this feasibility trial was the number of yoga sessions attended, with the intervention being deemed “feasible” if half of the participants completed at least 9 of 12 sessions. The secondary outcomes included change in pain as assessed by pre and post self-assessments using the standard 10-cm Visual Analog Scale for pain severity  and change in quality of life as assessed by the EQ-5D-3L. Qualitative data relating to participants' attitudes about the intervention and experience with the intervention were collected through interview. We conducted 30-min interviews consisting of 16 questions with each participant. We recorded their responses and analyzed the documentation for themes.
All study procedures were in accordance with the ethical standards of the Helsinki Declaration of 1975, revised in 2000, and were approved and monitored by the University of Wisconsin Institutional Review Board's Human Participants Committee.
Outcome analysis included all enrolled individuals who completed the yoga intake session with Dr. Hampton (intention to treat). Our primary outcome was an analysis of attendance at the yoga sessions; we defined the intervention as “acceptable” if at least half of the study participants attended 9 of the 12 yoga sessions. In addition, we compared pre/post pain and quality of life scores for all participants who attended at least one yoga session using a paired t-test. The last observation carried forward was applied to missing data. This study was not sufficiently powered to show significant results; mean difference and confidence intervals (CIs) before and after the intervention describe results. Statistical analysis was completed using GraphPad QuickCalcs (2018 version, GraphPad Software, 2365 Northside Dr., Suite 560, San Diego, CA 92108).
| Results|| |
Twenty-three potential participants were screened. Ten were eligible for study participation and were enrolled after signing consent. Of these, 6 attended at least 1 yoga class session. Reasons for not attending were as follows: 1 for planned surgery unrelated to the study protocol, 1 due to transportation problems, and 2 for personal circumstances unrelated to the study protocol. Of the 6 participants who attended at least 1 yoga session, 1 completed 9 sessions, 1 completed 6 sessions, 1 completed 5 sessions, 2 completed 3 sessions, and 1 completed 2 sessions.
Participants who completed at least 1 yoga session were self-assessed by the 10-cm Visual Analog Scale for pain severity. Pre and post pain severity was compared following completion of exit interviews using a paired t-test. The last observation carried forward was applied to missing data. Individuals showed a mean change of −2.4 cm from pre and post recordings (P = 0.028, 95% CI: −0.390–−4.477).
Participants who completed at least one yoga session were assessed by the EuroQol Five-Dimensional Questionnaire. Pre and post averages in quality of life were compared following exit interviews using a paired t-test. The last observation carried forward was applied to any missing data. The mean increase in the quality of life upon completion of the study was 0.26 points (P = 0.029, 95% CI: 0.04–0.47).
Qualitative data about participants' experience with the intervention were positive. In the exit interview, one participant reported, “Immediate benefit. It just gets better as you go along.” Another participant reported, “You can breathe pain out; that has helped a lot.” Two participant responses pointed to benefits beyond analgesia. One participant reported, “It helps your body and your mind,” whereas another reported, “It just relax you and make you feel happy. It gives you something to look forward to; something positive, because you know you can do it.”
In addition, participants were asked a series of open-ended questions to help identify the elements of the study they found helpful, areas that could be improved, and any barriers to engagement in study activities. Participants stated that helpful elements included the supportive group setting which provided motivation and accountability, acquisition of both immediate and longer-term pain relief techniques, and exposure to yoga as an additional option for pain management. One participant reported, “It helped with my pain. It was new and I think it was good; a new form of exercise and a form of relaxation.”
Difficulty with travel to a clinic for weekly sessions was a uniting theme among all exit interviews. In addition, participants suggested adding additional sessions throughout the week.
Following predefined criteria, this individually tailored yoga intervention was not deemed “feasible,” as fewer than 50% of participants completed 9 of 12 weekly yoga sessions. During qualitative data collection at exit interviews, participants cited many reasons for absenteeism from yoga sessions, including adverse weather conditions, transportation problems, and health complications not related to the study protocol. One participant stated simply that “life interfered.”
| Discussion|| |
Our study evaluated the feasibility of an individualized yoga intervention for chronic neck and back pain delivered in a group setting to a medically underserved population. The intervention was tailored to the individual, with personalized yoga, one-on-one time with the yoga teacher, and the drop-in nature of the weekly yoga sessions. While participation was low and feasibility criteria were not met, trends toward quality of life improvement and pain reduction are quite promising and within the generally accepted range of clinical significance. Our small sample size and limited data limit the scope of conclusions that can be drawn from our study.
Perhaps, the most useful in determining future directions for more definitive or extension studies was the qualitative feedback from exit interviews. Qualitative data suggest that the intervention was well-received and that external barriers prevented more robust participation. Future studies should focus on accessibility, specifically transportation, and number/timing of yoga sessions offered.
This research was supported by a small grant from the Department of Family Medicine and Community Health (DFMCH) at the University of Wisconsin–Madison. Adrienne Hampton was an Academic Integrative Medicine Fellow in DFMCH when she designed and directed this project, and Bruce Barrett was supported by a mid-career research and mentoring career grant from NIH NCCIH (K24AT006543). The authors would like to acknowledge the assistance of Mary Checovich with several aspects of this project and manuscript production and the participants who generously assisted this project.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
| References|| |
Institute of Medicine of the National Academies Report. Relieving Pain in America: A Blueprint for Transforming Prevention, Care, Education, and Research. Washington DC: The National Academies Press; 2011.
Blackwell DL, Lucas JW, Clarke TC. Summary health statistics for U.S. Adults: National health interview survey, 2012. Vital Health Stat 2014;10:1-61.
Chang DG, Holt JA, Sklar M, Groessl EJ. Yoga as a treatment for chronic low back pain: A systematic review of the literature. J Orthop Rheumatol 2016;3:1-8.
Wieland LS, Skoetz N, Pilkington K, Vempati R, D'Adamo CR, Berman BM. Yoga treatment for chronic non-specific low back pain. Cochrane Database Syst Rev 2017;1:CD010671.
Cramer H, Klose P, Brinkhaus B, Michalsen A, Dobos G. Effects of yoga on chronic neck pain: A systematic review and meta-analysis. Clin Rehabil 2017;31:1457-65.
Highland KB, Schoomaker A, Rojas W, Suen J, Ahmed A, Zhang Z, et al.
Benefits of the restorative exercise and strength training for operational resilience and excellence yoga program for chronic low back pain in service members: A pilot randomized controlled trial. Arch Phys Med Rehabil 2018;99:91-8.
Haefeli M, Elfering A. Pain assessment. Eur Spine J 2006;15 Suppl 1:S17-24.
Szende A, Oppe M, Devlin N, editors. EQ-5D Value Sets: Inventory, Comparative Review and User Guide. Dordrecht. The Netherlands: Springer; 2007.
Adrienne Renelle Hampton
Department of Family Medicine, University of Wisconsin, 3209 Dryden Drive, Madison, WI 53704
Source of Support: None, Conflict of Interest: None