November 2011 John Weeks Integrator Round-up: Research
The productive Group Health Research Institute group led by Karen Sherman, PhD and Daniel Cherkin, PhD report that yoga classes are effective in treating low back pain. The study was published as A Randomized Trial Comparing Yoga, Stretching, and a Self-care Book for Chronic Low Back Pain in Archives of Internal Medicine. However, the researchers concluded that while “yoga classes were more effective than a self-care book” these were “not more effective than stretching classes, in improving function and reducing symptoms due to chronic low back pain.” In both stretching and yoga, benefits were found to last “at least several months.” I asked Yoga therapist John Kepner, executive director of the International Association of Yoga Therapists, for his perspective on why the yoga classes were not better than stretching classes. He wrote:
“Re sham/stretching and yoga
“1. Karen (Sherman) had a good explanation – that the stretching classes were more “Yoga like” than the typical exercise program. “We expected back pain to ease more with yoga than with stretching, so our findings surprised us,” Dr. Sherman said. “The most straightforward interpretation of our findings would be that yoga’s benefits on back function and symptoms were largely physical, due to the stretching and strengthening of muscles.” But the stretching classes included a lot more stretching than in most such classes, with each stretch held for a relatively long time. “People may have actually begun to relax more in the stretching classes than they would in a typical exercise class,” she added. “In retrospect, we realized that these stretching classes were a bit more like yoga than a more typical exercise program would be.” So the trial might have compared rather similar programs with each other.
“2. But note, this study was focused on a very narrow definition of benefits, (reducing chronic low back pain). Yet the classical goal of Yoga is mental health, i.e., quieting the mind. The tangible and demonstrable integration of body breath and mind in a classic Yoga practice is focused on that. That was not measured here.
“3. When I ask my personal students the primary reason they come to Yoga class, the ‘benefits’ if you will, they will not say reducing pain. They say ‘defragging’ their brain, which I interpret as simply expressing the classic ‘quieting the fluctuation of the mind’ in modern terminology.
“4. The benefits of Yoga in reducing physical pain could be interpreted simply as positive ‘side effects’ of the practice -although they are not very inconsequential to a person in actual pain.”
The Group Health release is here. The publication was accompanied by a commentary from a primary care provider who considered the study an “excellent example of a pragmatic comparative effectiveness trial.” He recommended that physicians refer for the yoga or stretching classes.
Comment: This findings continue an interesting pattern from the Cherkin-Sherman team. Their examination of acupuncture found it more effective than usual care, but no more effective than “sham acupuncture.” An examination of massage therapy found a focused medical massage effective and reflection on many of our parts. It is intriguing to see Sherman’s view that the form or stretching may have tilted toward the more reflective and mind-slowing experience many find in yoga. Stretching can be a mind-body engagement. Meantime, Kepner’s perspective is a fun reversal, placing the back pain benefits as positive side effects of mind-spirit value of the Yoga therapy. A Cherkin-Sherman paper on positive side-effects is noted here.
“1. There was consensus that research toward policy objectives in the field is essential to the profession’s identity and advancement. Simultaneously, better focus on critical goals is needed. This means that research on naturopathic practice, naturopathic physicians and their patients, and naturopathic medical theory is required, and not simply studies on single agents and modalities. Broad outcome measures are necessary to measure the impact of naturopathic medicine on whole health and prevention, not just biomarkers of disease progression.
“2. The most compelling work has been and will be outcomes studies in naturopathic practice in comparison to conventional medical models, particularly on clinical effectiveness, safety, and cost, published in peer-reviewed journals.”
The participants in the Summit also concluded that “financial and other resources from the profession must be accessed” to develop the necessary information. The NMJ is the official publication of the American Association of Naturopathic Physicians, a Summit co-sponsor. (Alignment of interest note: I helped develop this meeting as a member of the NPRI board.)