Low back pain (LBP) is commonly experienced in the general population. It is estimated that about 80% of US adults experience LBP at some point.1 There are 3 main types of back pain, measured in terms of duration: (a) acute LBP is generally defined as an episode persisting for up to 6 weeks, (b) subacute LBP is pain that persists for 6 to 12 weeks,2 and (c) chronic LBP (CLBP) is defined as pain that persists for 3 months or longer.3–4 Based on clinical practice guidelines, acute LBP has a favorable prognosis, with 90% recovering within 6 weeks.5 A systematic review5 confirmed that most people with acute LBP have rapid improvement within 30 days.
Of the various types of chronic pain, chronic back pain is the most frequent type.6 People with CLBP are at increased risk of functional limitations, job-related disability, and potential long-term disability.7 CLBP often contributes to emotional distress, including depression, anxiety, sleep disturbance, and social isolation.8 Moreover, the economic burden of CLBP is high due to the cost of medications (eg, opioids), procedures, hospitalization, surgical treatment, and absence from work.9
Managing CLBP is a major public health issue, and no effective treatment has been identified.10 CLBP clinical practice recommends use of medications, self-care options, and nonpharmacological approaches.11 Studies have shown low use of nonpharmacological therapies to treat CLBP in clinical practice9; instead, pharmacological treatments, including opioids, are frequently prescribed.9,12 However, long-term use of opioids to control pain presents serious risks, including drug adverse events (eg, cognitive and psychomotor impairment, synergistic respiratory depression) and addiction/dependence leading to overdose death.13,14 The total cost for prescription opioids related to overdose, abuse, and dependence has been estimated at $70.0 billion to $87.3 billion.15 Efforts to reduce opioid use for pain management and to increase use of physically based therapies to reduce pain and increase physical function and safety in this population are needed.
Evidence-based clinical practice guidelines3 recommend that patients with CLBP use nonpharmacological treatments to manage their pain symptoms.8 Several nonpharmacological pain interventions have been tested in managing CLBP, including exercise and mind-body interventions. Exercise, including aerobic exercise, dynamic and isometric flexion or extension exercise, or stretching, are the most frequently used nonpharmacological approaches.16 Exercise has been effective in treating CLBP, and several randomized controlled trial (RCT) studies have found that exercise for LBP reduced pain intensity and improved functional ability.17 However, most effective and best exercise dose effects (ie, intensity, frequency, and duration) to use in patients with CLBP remain unclear or conflicting in the literature.18
Mind-body interventions, also called mind-body therapies, engage both the mind and body to reduce stress levels and improve psychological well-being by changing the way in which individuals respond to external or internal stressors.19 Mind-body interventions include various types: (a) meditation approaches (eg, mindfulness, mindfulness-based stress reduction), (b) hypnosis or guided imagery, (c) movement-based mind-body interventions (MMBI; eg, yoga, tai chi, and qigong), and (d) body-based approaches (eg, spinal manipulation, massage, mobilization, and acupuncture). MMBIs that combine physical poses with mindful relaxation and breathing techniques are expected to reduce pain intensity and improve physical function and emotional symptoms more than an exercise program that includes only physical components.20
Movement-based mind-body interventions
Of the various mind-body therapies, MMBIs are performed by synchronizing movements with breathing or by being mindful of body sensations during movement.19,21 MMBIs blend physical movement or physical posture and breathing with the mind to achieve a deep state of relaxation, defined as meditative movement.22 It is important to note that MMBIs such as yoga, tai chi, and qigong highlight the connection between mind and body, including mental exercise and body self-awareness.19 MMBIs are widely used to treat both psychological and physical symptoms associated with fibromyalgia,23 rehabilitation from physical and psychological trauma,24 balance issues and fall prevention,25 and efforts to improve resilience.26
Both tai chi and qigong, as MMBI, include slow controlled motions and focused breathing and are thought to enhance the body's energy or qi/chi.21 Regular practice of qigong provides a range of therapy recommended by most modalities, focused on the spine: gentle bending, stretching, and strengthening based on the functional integrity of the spine and connective mechanisms. Qigong has been shown to be effective for physical conditions and for psychological well-being, which could make it an alternative treatment for persons with CLBP.21 This article is a review of the effects of MMBI on LBP and a discussion of the implications of these interventions in patients with CLBP.
Purpose of the review
The purpose of this review was to evaluate the evidence of effects of MMBI on CLBP. The narrative review considers present evidence on 3 movement modalities that focus on back pain: yoga, tai chi, and qigong. The review compares and contrasts (a) types of MMBI, (b) frequency and duration of the interventions, (c) primary and secondary outcomes, (d) attrition rates and potential adverse events associated with the interventions, and (e) results. This review includes both randomized and nonrandomized studies. The rationale for this narrative review is that a comprehensive assessment of effects of mind-body interventions will provide information across disciplines to implement evidence-based interventions to reduce pain.
The narrative review approach27,28 may address one or more questions; selection criteria for inclusion of articles may not be explicit. This review follows the Academy of Nutrition and Dietetics Narrative Review Checklist,29 specifying parameters of the review (eg, years considered, language, publication status, study design, and databases covered).
A literature search was conducted to identify relevant peer-reviewed articles published in English in which a major topic was effects of MMBI, pain, psychological factors, coping strategies, and quality of life in people with back pain. The following scientific databases were searched, starting with the earliest dates available and the current date of the literature research (January 2019) without data limits: (a) PubMed/Medline, (b) Cumulative Index to Nursing and Allied Health Literature (CINAHL), (c) Elsevier, (d) PsycInfo, and (e) Cochrane.
An initial search using comprehensive search terms related to MMBI was completed to determine whether relevant articles could be identified. Search keywords (used alone or in combination) were (a) terms related to pain and back pain (back pain, low back pain, pain, and noncancer pain) and (b) movement-based mind-body interventions (yoga, tai chi, and qigong). Study selection was performed in 3 phases. First, the titles were skimmed and studies that did not meet the inclusion criteria were eliminated. Second, the authors reviewed abstracts and excluded the studies that did not meet selection criteria. Third, full articles were thoroughly reviewed to verify that the each met criteria. The following data were extracted from each article that was included in the study: design, study location (country), type of study sample (eg, retired athletes with nonspecific CLBP), sample size, mean age (standard deviation [SD]), type of MMBI, control group, frequency and duration of the MMBI, attrition, adverse events associated with the MMBI, and study findings.
Inclusion and exclusion criteria
The following selection criteria were applied: (a) participants with back pain, including chronic or acute pain; (b) MMBI (yoga, tai chi, and qigong) to manage back pain; (c) intervention study testing the effect of yoga, tai chi, or (and) qigong in participants diagnosed with back pain; and (d) experimental design (RCT) or a quasiexperimental, pretest-posttest repeated-measures design. Articles were excluded if they (a) did not study back pain, (b) were not written in English, (b) published a single case report, (c) were not intervention trials, or (d) were conference abstracts or dissertations.
A total of 625 articles were identified after the electronic database search by title was completed (509 articles for yoga, 85 for tai chi, and 31 for qigong). Abstracts of those 625 articles were reviewed; 447 articles (402 for yoga, 25 for tai chi, and 20 for qigong) that did not meet inclusion criteria were excluded, mainly due to their focus on other chronic pain conditions (fibromyalgia, migraine without aura, hip and knee osteoarthritis, and carpal tunnel syndrome). The remaining 149 studies were reviewed; 117 did not conduct an intervention study and were excluded. A total of 32 articles met inclusion criteria and were included for this review (Figure). Of the selected studies, a majority (25) reported yoga interventions, 4 reported tai chi interventions, and 3 reported qigong interventions in managing back pain. Most of the yoga studies were conducted in India, followed by the United States, while the other studies were conducted in Australia (tai chi) and Germany (qigong).
The 32 selected studies collected a total sample of 3484 subjects, with a mean age ranging from 33.45 years (SD = 3.5)30 to 73.00 years (SD = 5.6).31 Study sample sizes ranged from 2532 to 320.33 All 32 review studies (except one that examined the effects of tai chi on pain and muscle activity in Korean young males)34 focused on chronic back pain. One study, conducted in Germany, focused on older adults (≥65 years) with CLBP.31 Two studies by the same research team35,36 examined the effects of movement modality (yoga) in veterans, as many military veterans and active duty military personnel experience chronic pain.8 Compared to the general population, veterans are more likely to experience chronic pain.37 Only a few studies focused on older adults with back pain.38 Of the 25 studies that examined the effects of yoga on back pain, 1 focused on nursing professionals with CLBP,38 1 on low-resource adults with back pain,39 1 on information technology professionals with LBP,40 1 on premenopausal women with LBP,32 1 on minority populations with back pain,41 1 on beedi-rolling women with back pain,42 and 1 on office workers with CLBP.43 Of the tai chi studies, 1 focused on LBP,44,45 1 on nonspecific CLBP,46 and 1 on acute LBP.34
The Table shows the study characteristics of the selected studies. Of the 32 studies, 27 used RCT and 5 used a different design: quasiexperimental 2-group pretest/posttest, single-group pretest/posttest, longitudinal nonrandomized comparison, or 2-group pretest/posttest (Table). Most studies used a 2-arm RCT (mind-body intervention with comparable active control condition or wait-list control); 5 studies31,33,39,47,48 used 3-arm RCT; 1 used 4-arm RCT (tai chi was the experimental group with 3 active control condition groups: swimming, backward walking, and jogging).46
Seventeen studies (14 yoga, 2 tai chi, and 1 qigong) reported attrition rates, which ranged from 0%38 to 32%.34 In 1 yoga study,38 88 nurses with CLBP participated in a 60-minute/day, 5 days/week yoga or exercise intervention for 6 weeks; no one dropped out. Length of the 3 interventions ranged from 6 weeks to 1 year. Intensity and frequency included 20-minute sessions of yoga daily for 2 weeks,42 60-minute sessions of yoga 3 times a week for 12 weeks,31 and 75 minutes weekly for 12 weeks followed by 40 weeks of maintenance.39 Associated adverse events were reported in 3 interventions. Of the 32 studies, 11 yoga studies, 1 tai chi study, and 1 qigong study reported mild joint and back pain. In 1 study,48 1 yoga participant experienced a herniated disk but it was not reported whether the condition was directly related to the yoga intervention.48
A variety of pain measures was identified across the studies (Table). Seven studies employed a general numerical pain scale (eg, average pain level using 11-point numerical rating scale), 5 used visual analog scale (VAS; 0-100 mm, 0 = no pain, 100 = worst pain imaginable), and 4 used pain bothersomeness (a numerical rating scale). In addition, back pain scores on the Aberdeen Back Pain Scale49 and Oswestry Low Back Pain Disability50 scale were used. One study40 did not measure pain but measured only depression and anxiety, although they included information about technological professionals with LBP; it was not discussed how the participants were screened for LBP prior to the yoga intervention. Self-efficacy of pain and confidence in the ability to perform specific tasks despite back pain were measured using the Pain Self-Efficacy Questionnaire,51,52 Back Pain Self-Efficacy Scale,53 and Arthritis Self-Efficacy Scale.54
Instruments were mainly used to evaluate disability associated with acute or chronic back pain, led by the Roland-Morris Disability (RMQ) or modified RMQ, in which greater levels of disability are reflected by higher numbers on a 23-point scale, which was used in 10 studies (yoga, tai chi, or qigong). The Oswestry Disability Index, derived from the Oswestry Low Back Pain Questionnaire, was also administrated by clinicians or researchers to quantify disability from LBP. CLBP negatively affected quality of life (QoL), leading to reduced work productivity, absenteeism, and disabilities among nurses. Many studies included QoL as an outcome measure, using various QoL scales, including Short Form (SF)-12 or SF-36 Health-Related Quality of Life (HRQOL-4). Back-related functional status was used to measure physical function.55
Yoga is an alternative approach to treatment of LBP. Of the 25 yoga studies, 20 used an RCT (Table), 331,32,48 of which included a 3-arm parallel group stratified controlled trial. Participants in 3 studies were randomly assigned to yoga or other active control conditions (stretching48 and physical therapy32) or wait-list control18/usual care.21 Although a variety of types of yoga (eg, hatha yoga and Iyengar yoga) was available, only a few studies identified the specific type of yoga used in the study.
Of the 25 yoga studies, 20 reported positive outcomes in variables such as pain or psychological distress (eg, depression and anxiety), or energy. When 6-week yoga was compared to physical therapy,50 higher pain self-efficacy was the strongest predictor for reduced pain and higher function level for the yoga participants. However, no significant difference in treatment effect on pain and disability was seen between yoga and physical therapy at 6 weeks, which contrasts with studies that have reported yoga to be superior to back exercise or education in reducing back pain and disability.30,41,52,56 This result provides evidence that yoga is beneficial in treating back pain, although no significant improvement was identified when compared with other treatment modalities (eg, physical therapy).
Of the 11 studies that measured adverse events associated with yoga and/or other control conditions, 5 studies30,41,49,57,58 reported no adverse events in the yoga group. The rest reported mild or moderate adverse events: back pain or joint pain,39 increased pain,51 unspecified negative side effects,59,60 self-limited joint and back pain in yoga and physical therapy,32 and migraine headaches in a yoga session and strained back in the exercise control group.61 One participant in 1 RCT study48 experienced a herniated disk, but it was not reported whether the yoga intervention directly caused the problem.48
Yoga doses ranged from 20 minutes42 to 75 minutes39 over periods of 2 to 12 weeks; 4 studies32,35,40,58 did not report dosing (Table). Based on the outcomes in the reviewed studies, longer duration and high-dose yoga intervention showed reductions in back pain. In one yoga study,41 participants received 75 minutes of yoga for 12 weeks and reported less use of analgesics and opiates and overall improvement. In another study,52 use of medication and other outcomes were measured prior to and at the end of a 16-week yoga and education program. Participants were also encouraged to practice 20 minutes on nonclass days and were given a handout and CDs (yoga) or DVDs (stretching). Upon completion of 16 weeks of yoga, 88% in the yoga group reported decreasing or stopping medications and significant reductions in pain intensity and functional disability; this report was sustained at the 3-month follow-up assessment,52 when the yoga group showed significantly greater reduction in pain than the education group. In one study,48 228 adults with CLBP were randomly assigned to yoga, stretching exercises, or self-care (3-arm randomization). Weekly 75-minute yoga and stretching sessions were conducted for 12 weeks; small trials suggested that yoga may have had benefits for CLBP; the yoga group was significantly less bothered by symptoms than the self-care group at the end of the intervention.48
Limited research has been conducted on how yoga practice can relieve back pain. It is generally speculated that yoga emphasizes mental focus and breath as much as physical movement, which connects the mind and the body. Yoga can provide benefits for patients with back pain because it involves physical movement and also provides benefits through its effects on mental focus.30,32,48
Tai chi, as a gentle form of exercise that combines strengthening, stretching, and supervision, may assist in alleviating LBP.44–45 Four intervention studies34,44–46 tested the effects of tai chi for LBP. Duration ranged from 4 weeks34 to 6 months46; dosage ranged from 40 minutes per session twice a week44 to 45 minutes per session 5 days per week46 and 60 minutes per session 3 times per week.34 Tai chi included a variety of styles, generally based on number of movements. In one study,62 the Sun style form, promoted by arthritis foundations,63 was adopted. This style, compared with other styles, includes less knee flexion that leads to decreased stepping distance and increased follow-up steps. In one study, 4 main styles of tai chi—Chen, Wu, Yang, and Sun—were used. These 4 styles include slow movements with deep diaphragmatic breathing and an upright posture.62 Four cycles of the 24-step Chen style tai chi exercises were used in one study.46
Two studies compared tai chi to a wait-list control group45 or active control group: (a) “control group receives an intervention which controls for some aspects of attention, time, or expectation”64(p2) or (b) stretching.34 The combined results indicated that tai chi significantly reduced pain intensity and bothersomeness of back symptoms and improved self-reported disability on the RMQ.
Tai chi reduced acute LBP in males in their 20s.34 The study used RCT for acute LBP to investigate a 10-week tai chi intervention for reducing bothersomeness of pain and pain-related disability. The participants attended 60-minute sessions 3 times per week for 4 weeks. Statistically significant differences in pain reduction were identified between the intervention and control groups, as measured by the VAS. Tai chi was more effective than stretching for LBP in young males.34 For arthritis pain, tai chi has been demonstrated to have a small to moderate effect in reducing pain and improving physical function.62
A clinical trial44 assessed the effects of tai chi in patients with LBP in the general community. The 10-week tai chi exercise program was composed of postural and body awareness, lower extremity strengthening, static and dynamic balance, and gentle thoracic stretching.44 The intervention was delivered in a group format; bothersomeness of back symptoms was measured. The tai chi intervention showed greater reductions in pain intensity, bothersomeness of pain symptoms, and pain-related disability than the control intervention. One participant reported an increase in upper back pain that was relieved by correction with an upper extremity posture.
A double-blinded RCT evaluated effects of tai chi in improving nonspecific CLBP in retired athletes.46 The study had 4 control groups (swimming, jogging, backward walking, and no exercise). Participants were randomly assigned to either tai chi or 1 of the 4 control groups. The study results supported the initial hypothesis that tai chi is more effective in relieving pain in patients with nonspecific CLBP than the control activities. Swimming, jogging, and backward walking can strengthen muscles of the waist and lower body and improve flexibility of the vertebrae.46 Only 4 tai chi intervention studies were identified, 2 of which were conducted by the same research team. Although the 4 studies used RCT, the studies were of low methodological quality with small sample sizes.
Qigong is a traditional Chinese meditative movement therapy and includes specific features that focus on body awareness and attention during slow, relaxed, and fluid repetitive body movements.22 The current literature shows that qigong is associated with improvement in cardiovascular fitness and can help in improving psychological symptoms, immunological states, QoL, and physical health outcomes.65
Qigong is considered to be an alternative method for patients with CLBP.66 All 3 studies of qigong focused on CLBP; none focused on acute back pain. The stretching, loosening, strengthening, and balancing techniques of qigong release back tension, ease pain, and improve flexibility and alignment66; however, effects of qigong on back pain are inconclusive.66 One study67 reported that 10 of 127 participants reported adverse events (eg, muscle soreness, dizziness, pain, and mood fluctuation).
Only a few intervention studies have examined the effect of qigong on various types of pain: neck pain,68,69 fibromyalgia,70 and labor pain.71 Even fewer studies have focused on the effects of qigong on CLBP. One study67 examined the effects of qigong, compared with a wait-list control group, in office workers with chronic nonspecific LBP. The RCT was conducted at offices in Thailand, where 72 participants were randomly assigned to qigong or a control group. Qigong participants attended weekly 60-minute sessions for 6 weeks and were asked to practice qigong at home every day. Qigong participants reported decreased pain intensity, reduced back functional disability, and improved range of motion, core muscle strength, heart rate, respiratory rate, and mental status compared with the wait-list control group. It is plausible that 3 elements of the qigong program could reduce pain: posture, deep breathing, and meditation. However, when qigong practice was compared with exercise therapy as an active control condition, it failed to provide statistical significance, P = .204.67
In one study,67 participants were randomly assigned 1:1 to receive either qigong (90 minutes once per week for 3 months) or exercise therapy (60 minutes once a week for 12 weeks). As the primary outcome, pain intensity was measured after 3 months and at 6- and 12-month follow-up. Qigong was not shown to be superior to exercise therapy for managing CLBP. Qigong's role in the prevention of CLBP might be addressed in future studies.67
A combination of qigong with other alternative therapies may be used when treating patients with chronic conditions; however, 2 intervention studies31,67 focusing on CLBP failed to generate significant differences between qigong and other active control conditions. One study31 assessed effects of qigong or yoga in reducing CLBP in older adults. When compared to no intervention as a control group, qigong seemed to be effective. However, when qigong was compared to active control conditions and a wait-list control group, it did not show significant improvement. No significant group difference in pain intensity (primary outcome) was identified among the yoga, qigong, and control groups. Participation in a 3-month yoga or qigong intervention did not improve back function, depression, risk of falls, or QoL more than no intervention (wait-list group). To date, with only 3 qigong studies, it is unclear whether qigong is useful in treating CLBP. In RCT studies, it was not found that qigong was more effective than exercise or other alternative therapies.
Yoga, tai chi, and qigong provided empirical evidence regarding benefits that have been recommended by health care providers for the patients with LBP. A majority of the 32 reviewed articles showed MMBI to be effective for treatment of LBP, reporting positive outcomes such as reduction in pain or psychological distress (eg, depression and anxiety), reduction in pain-related disability, and improved functional ability. In this comprehensive literature review of back pain, not limited to chronic back pain, only 1 of the 32 studies examined the effect of MMBI (ie, tai chi) in acute LBP because it is plausible that acute LBP is often treated by pharmacological methods (eg, nonsteroidal anti-inflammatory drugs) as the first line of the treatment, then referred for spinal manipulation for patients who failed to resume daily activities.2
This narrative review provides emerging evidence that MMBI could benefit patients with LBP. In the selected studies, 3 interventions were delivered in group settings rather than individual practice, although the participants were encouraged to practice at home after group sessions. Some evidence supports the effects of 3 interventions for LBP (Table). In addition to pain reduction, secondary outcomes such as improvement in self-efficacy, pain, back function, mood, coping strategies, and/or QoL were sparse. There was evidence that MMBIs are effective for LBP; the new evidence strengthens previous conclusions regarding effectiveness of yoga. However, little is known about the effects of MMBI, particularly qigong and tai chi. Moreover, little attention has been devoted to evaluating how components of each intervention can improve LBP. It should be acknowledged that a relatively small number of intervention studies have examined the effect of qigong or tai chi in managing LBP.
Through methodological assessment, it was identified that 26 reviewed studies used RCT; however, most studies did not report in detail the specific process of randomization, allocation concealment, or blinding. Some of the studies did not report group differences between intervention and control groups, although they reported within-groups differences in the intervention. Most of the studies did not present a flow diagram to show the process from recruiting and screening eligible participants to completing the intervention.
MMBIs are considered safe, with relatively few published adverse events (eg, joint or back pain, muscle soreness, dizziness, and headache). However, the patterns of practices should inform future studies.19 The longer duration of 3 interventions (eg, 10-week tai chi45) seemed to be more effective than shorter-duration interventions (eg, 2-week yoga42) in reduction of pain and pain-related disability. For patients with acute LBP, a short-term intensive tai chi (3 times per week for 4 weeks) was more effective than stretching.
In one study,31 both tai chi and qigong with wait-list controls were compared in terms of the effects of the 2 interventions. No significant difference in improvement of chronic back pain and other physical and psychological symptoms was observed among the 3 groups. Since qigong and tai chi originated from similar foundations, many interventions include combined aspects of these 2 practices.72 Also, 3 months of qigong or yoga practice may not be sufficient to determine effects in pain perception, back function, other psychological symptoms (depression), or QoL because participants have suffered from CLBP for a long period.31
All 3 interventions in the reviewed studies were reported to be associated with mild levels of adverse events (eg, increased minor pain). Limited evidence from this research suggests a need to examine the effects of qigong or tai chi for persons with back pain. Existing research suggests positive benefits of yoga; however, tai chi and qigong for LBP are still underinvestigated. The movement modalities (yoga, qigong, and tai chi) that met inclusion criteria for this review share the common component of physical poses or movement with mediation or/and relaxation, as a mind-body therapy. While focusing primarily on body movements, these modalities are coupled with a mindful state by breathing exercises and relaxation. The holistic approach of body and mind interventions can be safely practiced.19
Regarding the instruments, the RMQ that measures severity of functional disability due to back pain was most frequently used in the reviewed studies, rather than pain intensity measures. The attrition rates of 3 movement interventions were relatively low; however, one study73 reported that yoga participants had similar or much higher attrition rates than controls (40% for yoga vs 10% for controls). Reported adverse events included increased back pain and migraine headaches. It would be important to confirm whether these reported adverse events resulted from performing the intervention or from comorbidities. No formal suggestion can be provided without clear understanding of the potential risks associated with the 3 MMBIs. Only 10 of the 32 reviewed studies reported adverse events (eg, increased pain and muscle soreness) from yoga, tai chi, or qigong, and those reported low prevalence and mild severity.
In addition to reporting attrition rates and increased adverse events, reporting the effect size of the movement therapies compared with usual care is useful to know when evaluating effects of the interventions. Most of the selected studies reported statistical significance in pain and other secondary outcomes without reporting an effect size.
LIMITATIONS AND NURSING IMPLICATIONS
The researchers acknowledge notable limitations. First, this review included only 3 types of mind-body interventions, although other types (eg, acupuncture, spinal manipulation, and massage therapy) were identified for managing back pain74 because this review focused on movement-based mind-body including body movement and physical posture, as well as meditation and breathing techniques. Second, of the 32 selected articles, 50% (16 articles) were conducted outside the United States (eg, Germany and India). Since this review study was limited to articles published in English, it is possible that important findings from articles published in other languages were not identified.
Third, although we conducted a narrative review of the evidence for 3 MMBIs in improving back pain, meta-analysis for increasing precision in estimating effects75 of 3 interventions was not performed because some of the selected studies showed low methodological quality and did not report an effect size across the studies. Finally, compared with meta-analysis, narrative review could be subjective in evaluating methodological quality of the studies since no objective measure (eg, Downs & Black's Quality Index checklist76) was used for assessing the selected articles in this review. Due to very few studies testing of the interventions, particularly qigong and tai chi, more rigorous intervention studies and high methodological quality are necessary to reach consistent findings on the effects of the 3 interventions.
More consistent evidence is required to encourage nurse practitioners and other health care providers to prescribe one of the MMBIs to patients to manage chronic back pain and refer them to mind-body interventionists such as certified yoga, tai chi, or qigong therapists. Guidelines for clinicians depend on the severity (mild, moderate, and severe) and duration (eg, 3 months, 6 months, and 2 years) of CLBP to determine the most appropriate dose-response, including intensity (eg, sessions of 30 minutes, 45 minutes), frequency (eg, 3 times per week), and duration (eg, 3 months, 6 months).
RCT with high methodological quality should be used, including assessor-blind RCT (ie, assessor measuring the main outcome of the intervention) and loss to follow-up should be considered using the intention-to-treat analysis. It should also be reported whether a fidelity check was completed by an evaluator independent of the research team. Accuracy in the presentation of the intervention should be reported. Long-term effects should be assessed with sufficient follow-up data. Although limitations of this review are recognized, the results may be useful for practitioners in determining the efficacy of MMBI in patients with LBP.
The review study notes a need for future clinical trials to measure the effects of MMBI to identify appropriate treatments for patients with back pain. In particular, older adults and veterans are more vulnerable, considering the prevalence of back pain in the population. The rate of CLBP in veterans tends to increase with longer follow-up periods and with more intensive levels of training and combat77 and LBP is the most prevalent health condition in older adults leading to functional limitations and disability.78 More than 17 million older adults (≥65 years) in the United States are reported to experience at least one episode of LBP annually.79
MMBI could be a treatment option for veterans or older adults with CLBP in improving physical conditions and psychological well-being. Currently, clinical practice recommends use of medications, self-care options, and nonpharmacological approaches.11 Optimal back pain treatment appears to be a major goal.11 However, a majority of patients focus on pharmacological treatment, surgery, or nonpharmacological treatment (eg, physical therapy, transcutaneous electrical nerve stimulation). The reviewed movement-based interventions can be used for managing physical conditions and for improving psychological well-being, which could be a valuable mind-body therapy for patients with LBP. However, using such interventions for back pain should be explored further.
It is important for nurse practitioners to consider mind-body interventions (eg, yoga, tai chi, and qigong) as treatment options for managing back pain. Nurse practitioners or other health care providers seek to identify the most effective MMBI for patients to reduce back pain and emotional distress associated with back pain and to promote QoL. Providers may introduce such mind-body interventions for managing pain, especially for those who are at high risk for adverse effects from opioids or other pain medications (eg, stomach ulcer, liver or kidney problem). Patients can be referred to a yoga therapist, tai chi therapist, or qigong therapist. It is suggested that nurse practitioners discuss with patients alternative nonpharmacological approaches to manage LBP.
The narrative review evaluated evidence of the effects of yoga, tai chi, and qigong on CLBP. This comprehensive evaluation provided the findings from 3 interventions to confirm whether they are safe, effective, and feasible for treatment of patients with LBP. A total of 32 articles selected for this review showed that the 3 interventions provided positive outcomes in back pain and other related outcomes including pain-related disability, quality of life to manage back pain, reduce pain-related disability, and improve QoL. The 3 MMBIs could be used as effective treatment alternatives to pain medications, surgery, or injection-based treatments (eg, nerve blocks) that are associated with high incidence of adverse effects in treating LBP. However, more empirical evidence on such outcomes from rigorous studies on such interventions is needed so that nurse practitioners can prescribe such interventions with confidence for managing LBP.
1. National Institute of Neurological Disorders and Stroke. Low back pain fact sheet. https://www.ninds.nih.gov/Disorders/Patient-Caregiver-Education/Fact-Sheets/Low-Back-Pain-Fact-Sheet
. Published 2018. Accessed January 10, 2019.
2. Van Tulder M, Becker A, Bekkering T, et al Chapter 3: European guidelines for the management of acute nonspecific low back pain in primary care. Eur Spine J. 2006;15:s169–s191.
3. American College of Physicians. Noninvasive treatment for acute, subacute, and chronic low back pain: a clinical practice guideline from the American College of Physicians. http://annals.org/aim/fullarticle/2603228/noninvasive-treatments-acute-subacute-chronic-low-back-painclinical-Practice
. Published 2017. Accessed December 29, 2018.
4. Treede RD, Rief W, Barke A, et al A classification of chronic pain for ICD-11. Pain. 2015;156(6):1003.
5. Pengel LH, Herbert RD, Maher CG, Refshauge KM. Acute low back pain: systematic review of its prognosis. Brit Med J. 2003;327:1–5.
6. Shmagel A, Foley R, Ibrahim H. Epidemiology of chronic low back pain in US adults: data from the 2009–2010 National Health and Nutrition Examination Survey. Arthritis Care Res (Hoboken). 2016;68:1688–1694.
7. Salvetti MDG, Pimenta CADM, Braga PE, Corrêa CF. Disability related to chronic low back pain: prevalence and associated factors. Rev Esc Enferm USP. 2012;46:16–23.
8. National Center for Complementary and Integrative Health. Complementary health practices for U.S. military, veterans, and families. https://nccih.nih.gov/health/military-veteran
. Published 2018. Accessed December 23, 2018
9. Gore M, Tai KS, Sadosky A, Leslie D, Stacey BR. Use and costs of prescription medications and alternative treatments in patients with osteoarthritis and chronic low back pain in community-based settings. Pain Prac. 2012;12:550–560.
10. Foster NE. Barriers and progress in the treatment of low back pain. BMC Med. 2011;9(1):1–5.
11. Chou R, Huffman LH. Nonpharmacologic therapies for acute and chronic low back pain: a review of the evidence for an American Pain Society/American College of Physicians clinical practice guideline. Ann Int Med. 2007;147:492–504.
12. Deyo RA, Smith DH, Johnson ES, et al Opioids for back pain patients: primary care prescribing patterns and use of services. JAMA Intern Med. 2011;24:717–727.
13. Banerjee G, Edelman EJ, Barry DT, et al Non-medical use of prescription opioids is associated with heroin initiation among US veterans: a prospective cohort study. Addiction. 2016;111:2021–2031.
14. Miller M, Barber CW, Leatherman S, et al Prescription opioid duration of action and the risk of unintentional overdose among patients receiving opioid therapy. JAMA Intern Med. 2015;175:608–615.
15. Florence C, Luo F, Xu L, Zhou C. The economic burden of prescription opioid overdose, abuse and dependence in the United States, 2013. Med Care. 2016;54:901–906.
16. Van Middelkoop M, Rubinstein SM, Kuijpers T, et al A systematic review on the effectiveness of physical and rehabilitation interventions for chronic non-specific low back pain. Eur Spine J. 2011;20(1):19–39.
17. Airaksinen O, Brox JI, Cedraschi C, et al Chapter 4: European guidelines for the management of chronic nonspecific low back pain. Eur Spine J. 2006;15:s192–s300.
18. Henchoz Y, Kai-Lik So A. Exercise and nonspecific low back pain: a literature review. Joint Bone Spine. 2008;75:533–539.
19. Lee C, Crawford C, Hickey A. Mind-body therapies for the self-management of chronic pain symptoms. Pain Med. 2014;15(S1):S21–S39.
20. Black DS, O'Reilly GA, Olmstead R, Breen EC, Irwin MR. Mindfulness meditation and improvement in sleep quality and daytime impairment among older adults with sleep disturbances: a randomized clinical trial. JAMA Intern Med. 2015;175:494–501.
21. Morone NE, Greco CM. Mind-body interventions for chronic pain in older adults: a structured review. Pain Med. 2007;8:359–375.
22. Larkey L, Jahnke R, Etnier J, Gonzalez J. Meditative movement as a category of exercise: implications for research. J Phys Act Health. 2009;6:230–238.
23. Langhorst J, Klose P, Dobos GJ, Bernardy K, Häuser W. Efficacy and safety of meditative movement therapies in fibromyalgia syndrome: a systematic review and meta-analysis of randomized controlled trials. Rheumatol Int. 2013;33(1):193–207.
24. Telles S, Naveen KV. Yoga
for rehabilitation: an overview. Indian J Med Sci. 1997;51(4):123–127.
25. Low S, Ang LW, Goh KS, Chew SK. A systematic review of the effectiveness of Tai Chi
on fall reduction among the elderly. Arch Gerontol Geriat. 2009;48:325–331.
26. Stoller CC, Greuel JH, Cimini LS, Fowler MS, Koomar JA. Effects of sensory-enhanced yoga
on symptoms of combat stress in deployed military personnel. Am J Occup Ther. 2012;66(1):59–68.
27. Ferrari R. Writing narrative style literature reviews. Med Writing. 2015;24(4):230–235.
28. Green BN, Johnson CD, Adams A. Writing narrative literature reviews for peer-reviewed journals: secrets of the trade. J Chiro Med. 2006;5(3):101–117.
29. Handu D, Moloney L, Wolfram T, Ziegler P, Acosta A, Steiber A. Academy of Nutrition and Dietetics methodology for conducting systematic reviews for the Evidence Analysis Library. J Acad Nutr Diet. 2016;116(2):311–318.
30. Patil NJ, Nagaratna R, Tekur P, Manohar PV, Bhargav H, Patil D. A randomized trial comparing effect of yoga
and exercises on quality of life in among nursing population with chronic low back pain. Int J Yoga
31. Teut M, Knilli J, Daus D, Roll S, Witt CM. Qigong
versus no intervention in older adults with chronic low back pain: a randomized controlled trial. J Pain. 2016;17(7):796–805.
32. Lee M, Moon W, Kim J. Effect of yoga
on pain, brain-derived neurotrophic factor, and serotonin in premenopausal women with chronic low back pain. Evidence Based Complement Alternat Med. 2014:1–8.
33. Saper RB, Lemaster C, Delitto A, et al Yoga
, physical therapy, or education for chronic low back pain: a randomized noninferiority trial. Ann Intern Med. 2017;167:85–94.
34. Cho Y. Effects of tai chi
on pain and muscle activity in young males with acute low back pain. J Phys Ther Sci. 2014;2:679–681.
35. Groessl EJ, Weingart KR, Aschbacher K, Pada L, Baxi S. Yoga
for veterans with chronic low-back pain. J Altern Complement Med. 2008;14:1123–1129.
36. Groessl EJ, Weingart KR, Johnson N, Baxi S. The benefits of yoga
for women veterans with chronic low back pain. J Altern Complement Med. 2012;18:832–838.
37. National Center for Complementary and Integrative Health. Veterans endure higher pain severity than nonveterans: national analysis includes first-ever comparison of pain prevalence, severity in veterans by age and sex. https://nccih.nih.gov/news/press/veterans_pain
. Published 2016. Accessed January 20, 2019.
38. Weiner DK, Haggerty CL, Kritchevsky SB, et al How does low back pain impact physical function in independent, well-functioning older adults? Evidence from the Health ABC Cohort and implications for the future. Pain Med. 2003;4:311–320.
39. Ostrovsky DA. Yoga
may be noninferior to physical therapy for disability and pain at 12 weeks and both might improve function more than education in low resource adults with chronic nonspecific low back pain. Explore (NY). 2017;13:424–426.
40. Sunil P, Kumari S. Effect of yoga
module on low back pain in information technology professionals. Int J Educ Psychol Res. 2016;2:234–237.
41. Saper RB, Sherman KJ, Cullum-Dugan D, Davis RB, Phillips RS, Culpepper L. Yoga
for chronic low back pain in a predominantly minority population: a pilot randomized controlled trial. Altern Ther Health Med. 2009;15(6):18–27.
42. Jacob AM, Kathyayani BV. A study to assess the effectiveness of yogic postures on back pain among beedi rolling women in a selected rural area at Mangalore. Int J Nurs Educ. 2017;9(2):1–5.
43. Phattharasupharerk S, Purepong N, Eksakulkla S, Siriphorn A. Effects of qigong
practice in office workers with chronic non-specific low back pain: a randomized control trial. J Bodyw Mov Ther. 2019;23(2):375–381.
44. Hall AM, Kamper SJ, Emsley R, Maher CG. Does pain-catastrophising mediate the effect of tai chi
on treatment outcomes for people with low back pain? Complement Ther Med. 2016;25:61–66.
45. Hall AM, Maher CG, Lam P, Ferreira M, Latimer J. Tai chi
exercise for treatment of pain and disability in people with persistent low back pain: a randomized controlled trial. Arthritis Care Res (Hoboken). 2011;63:1576–1583.
46. Weifen W, Muheremu A, Chaohui C, Lei S. Effectiveness of tai chi
practice for non-specific chronic low back pain on retired athletes: a randomized controlled study. J Musculoskel Pain. 2013;21(1):37–45.
47. Brämberg EB, Bergström G, Jensen I, Hagberg J, Kwak L. Effects of yoga
, strength training and advice on back pain: a randomized controlled trial. BMC Musculoskelet Disord. 2107;18(1):1–11.
48. Sherman KJ, 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;171:2019–2026.
49. Monro R, Bhardwaj AK, Gupta RK, Telles S, Allen B, Little P. Disc extrusions and bulges in nonspecific low back pain and sciatica: exploratory randomised controlled trial comparing yoga
therapy and normal medical treatment. J Back Musculoskelet Rehab. 2015;28:383–392.
50. Kuvačić G, Fratini P, Padulo J, Antonio DI, De Giorgio A. Effectiveness of yoga
and educational intervention on disability, anxiety, depression, and pain in people with CLBP: a randomized controlled trial. Complement Ther Clin Prac. 2018;31:262–267.
51. Evans DD, Carter M, Panico R, Kimble L, Morlock JT, Spears MJ. Characteristics and predictors of short-term outcomes in individuals self-selecting yoga
or physical therapy for treatment of chronic low back pain. Phys Med Rehab. 2010;2:1006–1015.
52. Tilbrook HE, Cox H, Hewitt CE, et al Yoga
for chronic low back pain: a randomized trial. Ann Intern Med. 2011;155(9):569–578.
53. Williams KA, Petronis J, Smith D, et al Effect of Iyengar yoga
therapy for chronic low back pain. Pain. 2005;115(1/2):107–117.
54. Sherman KJ, Wellman RD, Cook AJ, Cherkin DC, Ceballos RM. Mediators of yoga
and stretching for chronic low back pain. Evid Based Complement Alternat Med. 2013;2013:130818.
55. Fairbank JC, Pynsent PB. The Oswestry Disability Index. Spine. 2000;25:2940–2953.
56. Sherman KJ, Cherkin DC, Cook AJ, et al Comparison of yoga
versus stretching for chronic low back pain: protocol for the Yoga
Exercise Self-care (YES) trial. Trials. 2010;11(1):36.
57. Telles S, Bhardwaj AK, Gupta RK, Sharma SK, Monro R, Balkrishna A. A randomized controlled trial to assess pain and magnetic resonance imaging-based (MRI-based) structural spine changes in low back pain patients after yoga
practice. Med Sci Monit. 2016;22:3238–3247. doi:10.12659/MSM.896599.
58. Tekur P, Chametcha S, Hongasandra RN, Raghuram N. Effect of yoga
on quality of life of CLBP patients: a randomized control study. Int J Yoga
. 2010;3(1):10–17. doi:10.4103/0973-6131.66773.
59. Highland KB, Schoomaker A, Rojas W, et al Benefits of the restorative exercise and strength training for operational resilience and excellence yoga
program for chronic low back pain in service members: a pilot randomized controlled trial. Arch Phys Med Rehab. 2018;99(1):91–98.
60. Saper RB, Boah AR, Keosaian J, Cerrada C, Weinberg J, Sherman KJ. Comparing once-versus twice-weekly yoga
classes for chronic low back pain in predominantly low income minorities: a randomized dosing trial. Evid Based Complement Alternat Med. 2013:2013:1–14.
61. 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;143:849–856.
62. Hall AM, Maher CG, Latimer J, Ferreira ML, Lam P. A randomized controlled trial of tai chi
for long-term low back pain (tai chi
): Study rationale, design, and methods. BMC Musculoskelet Dis. 2009;10(1):55–61.
64. Kinser PA, Robins JL. Control group design: enhancing rigor in research of mind-body therapies for depression. Evidence Based Complement Alternat Med. 2013;2013:140467.
65. Rogers CE, Larkey LK, Keller C. A review of clinical trials of tai chi
in older adults. Western J Nurs Res. 2009;31:245–279.
66. Bai Z, Guan Z, Fan Y, Liu C, et al The effects of qigong
for adults with chronic pain: systematic review and meta-analysis. Am J Chinese Med. 2015;43:1525–1539.
67. Blödt S, Pach D, Kaster T, et al Qigong
versus exercise therapy for chronic low back pain in adults: a randomized controlled non-inferiority trial. Eur J Pain. 2015;19(1):123–131.
68. Rendant D, Pach D, Lüdtke R, et al Qigong
versus exercise versus no therapy for patients with chronic neck pain: a randomized controlled trial. Spine. 2011;36:419–427.
69. von Trott P, Wiedemann AM, Lüdtke R, Reißhauer A, Willich SN, Witt CM. Qigong
and exercise therapy for elderly patients with chronic neck pain (QIBANE): a randomized controlled study. J Pain. 2009;10:501–508.
70. Lynch M, Sawynok J, Hiew C, Marcon D. A randomized controlled trial of qigong
for fibromyalgia. Arthritis Res Ther. 2012;14(4):1–11.
71. Jeong SO, Lee EJ. Effects of a qigong
training program on the anxiety and labor pain of primipara. Korean J Women Health Nur. 2006;12(2):97–105.
72. Jahnke R, Larkey L, Rogers C, Etnier J, Lin F. A comprehensive review of health benefits of qigong
and tai chi
. Am J Health Prom. 2010;24:e1–e25. doi:10.4278/ajhp.08013-LIT-248.
73. Cox H, Tilbrook H, Aplin J, et al A randomised controlled trial of yoga
for the treatment of chronic low back pain: results of a pilot study. Complement Ther Clin Prac. 2010;16(4):187–193.
74. NCCIHN. Mind and body approaches for chronic pain: what the science says. https://www.ninds.nih.gov/Disorders/Patient-Caregiver-Education/Fact-Sheets/Low-Back-Pain-Fact-Sheet
. Accessed March 2, 2019.
75. Walker E, Hernandez AV, Kattan MW. Meta-analysis: its strengths and limitations. Cleveland Clin J Med. 2008;75(6):431–439.
76. Downs SH, Black N. The feasibility of creating a checklist for the assessment of the methodological quality both of randomised and non-randomised studies of health care interventions. J Epidemiol Community Health. 1998;52:377–384.
77. Salamon R, Verret C, Jutand MA, et al Health consequences of the first Persian Gulf War on French troops. Int J Epidemiol. 2006;35:479–487.
78. Helme RD, Gibson SJ. The epidemiology of pain in elderly people. Clin Geriatr Med. 2001;17:417–431.
79. Lawrence RC, Helmick CG, Arnett FC, et al Estimates of the prevalence of arthritis and selected musculoskeletal disorders in the United States. Arthritis Rheum. 1998;41:778–799.
80. Gatantino ML, Bzdewka TM, Eissler-Rnsso JL, et al The impact of modified Hatha yoga
on chronic low back pain: a pilot study. Altern Ther Health Med. 2004;10(2):56–59.
81. Nambi GS, Inbasekaran D, Khuman R, Devi S. Changes in pain intensity and health-related quality of life with Iyengar yoga
in nonspecific chronic low back pain: a randomized controlled study. Int J Yoga
. 2014;7(1):48–53. doi:10.4103/0973-6131.123481.