Yoga Noninferior to Physical Therapy for Chronic Low Back Pain

yoga for low back pain
yoga for low back pain
Yoga was deemed noninferior to physical therapy for the treatment of patients with chronic low back pain.

In a randomized trial that compared the efficacy of yoga, physical therapy (PT), and education for patients with chronic low back pain (cLBP), yoga was deemed noninferior to PT.1

Given the high disability and economic burden of cLBP in the United States, affecting 10% of American adults and costing more than $200 billion annually, the researchers sought to investigate more cost-effective, nonpharmacologic pain relief.2 As a result, guidelines for cLBP now recommend nonpharmacologic treatments ahead of pharmacotherapy, although moderate effects obtained by such interventions are supported by low- to moderate-quality evidence.3 Patients with cLBP and low socioeconomic status are disproportionately affected.4

The randomized noninferiority trial was conducted in an urban academic hospital and community clinics that serve low-income patients ( identifier: NCT01343927). Adult patients (n=320; aged 18-64 years) with nonspecific LBP who had a pain intensity rating of ≥4 on a 0 to 10 scale were randomly assigned at a 2:2:1 ratio to yoga, PT, or education for 12 weeks of treatment followed by 40 weeks of maintenance.

To ensure patients received standardized treatment, yoga instructors and physical therapists underwent training and followed instructions from the same manual for their respective sessions. Both yoga and PT had a home maintenance component, during which in-person sessions of PT and yoga were compared with home practice.

The educational treatment consisted of giving patients 2-page newsletters every 3 weeks and a book, The Back Pain Helpbook, which had been used as a comparator in previous trials demonstrating yoga’s superiority to educational interventions.4-6

The primary end points measured at 12 weeks were pain (assessed using an 11-point rating scale) and function based on the Roland Morris Disability Questionnaire (noninferiority margins, 1.0 and 1.5, respectively). Secondary end points included medication use, global improvement, intervention satisfaction, and health-related quality of life.

Yoga was found to be noninferior to PT, but not superior to education. The mean difference in disability between yoga and PT was −0.26 (95% CI, ∞ to 0.83); for pain, the mean difference between yoga and PT was 0.51 (95% CI, ∞ to 0.97). The mean difference in disability between yoga and education was −1.3 (95% CI, −2.8 to 0.25); for pain, the difference was −0.33 (95% CI, −0.97 to 0.32).

Overall, yoga and PT outperformed education in all secondary end points. Patients who participated in yoga and PT tended to use less pain medication than patients who received education (odds ratio [OR], 0.36 [95% CI, 0.17-0.78] and 0.31 [95% CI, 0.14-0.67], respectively).

“These findings suggest that a manualized yoga intervention designed specifically for cLBP is similarly effective to PT for improving physical function and reducing pain in a diverse underserved population with high levels of impairment,” observed the researchers. “A structured yoga program for patients with cLBP may be a reasonable alternative to PT depending on patient preferences, availability, and cost.”

Summary and Clinical Applicability

Although already included in pain guidelines as an effective therapy, yoga may become more prominent as a treatment modality for payers seeking cost-effective treatments for LBP.


There was a disproportionate number of patients in the PT group lost to follow-up, which may have biased the results.

Because of the nature of the modalities assessed, the study could not be blinded.


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  1. Saper RB, Lemaster C, Delitto A, et al. Yoga, Physical therapy, or education for chronic low back pain: a randomized noninferiority trial [published online June 20, 2017]. Ann Intern Med. doi: 10.7326/M16-2579
  2. Ma VY, Chan L, Carruthers KJ. Incidence, prevalence, costs, and impact on disability of common conditions requiring rehabilitation in the United States: stroke, spinal cord injury, traumatic brain injury, multiple sclerosis, osteoarthritis, rheumatoid arthritis, limb loss, and back pain. Arch Phys Med Rehabil. 2014;95:986-995. doi: 10.1016/j.apmr.2013.10.032
  3. Qaseem A, Wilt TJ, McLean RM, Forciea MA. Clinical Guidelines Committee of the American College of Physicians. Noninvasive treatments for acute, subacute, and chronic low back pain: a clinical practice guideline from the American College of Physicians. Ann Intern Med. 2017;166:514-530. doi: 10.7326/M16-2367
  4. Moore J, Lorig K, Von Korff M, Gonzalez V, Laurent DD. The Back Pain Helpbook. Reading, MA: Perseus; 1999.
  5. Sherman KJ, Cherkin DC, Erro J, Miglioretti DL, Deyo RA. Comparing yoga, exercise, and a self-care book for chronic low back pain: a randomized, controlled trial. Ann Intern Med. 2005;143(12):849-856. doi: 10.7326/0003-4819-143-12-200512200-00003
  6. Sherman KJ1, Cherkin DC, Wellman RD, et al. A randomized trial comparing yoga, stretching, and a self-care book for chronic low back pain. Arch Intern Med. 2011;171(22):2019-2026. doi: 10.1001/archinternmed.2011.524