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Yoga for Chronic Low Back Pain: A Randomized Trial Tilbrook HE, Cox H, et al. The Annals of Internal Medicine 2011: 155 (November): 569-578
BACKGROUND: Previous studies indicate that yoga may be an effective treatment for chronic or recurrent low back pain.
OBJECTIVE: To compare the effectiveness of yoga and usual care for chronic or recurrent low back pain.
DESIGN: Parallel-group, randomized, controlled trial using computer generated randomization conducted from April 2007 to March 2010. Outcomes were assessed by postal questionnaire.
SETTING: Thirteen non–National Health Service premises in the United Kingdom.
PATIENTS: Three hundred thirteen adults with chronic or recurrent low back pain.
INTERVENTION: Yoga (n =156) or usual care (n = 157). All participants received a back pain education booklet. The intervention group was offered a 12-class, gradually progressing yoga program delivered by 12 teachers over 3 months.
MEASUREMENTS: Scores on the Roland–Morris Disability Questionnaire (RMDQ) at 3 (primary outcome), 6, and 12 (secondary outcomes) months; pain, pain self-efficacy, and general health measures at 3, 6, and 12 months (secondary outcomes).
RESULTS: Ninety-three (60%) patients offered yoga attended at least 3 of the first 6 sessions and at least 3 other sessions. The yoga group had better back function at 3, 6, and 12 months than the usual care group. The adjusted mean RMDQ score was 2.17 points (95% CI,1.03 to 3.31 points) lower in the yoga group at 3 months, 1.48 points (CI, 0.33 to 2.62 points) lower at 6 months, and 1.57 points (CI, 0.42 to 2.71 points) lower at 12 months. The yoga and usual care groups had similar back pain and general health scores at 3, 6, and 12 months, and the yoga group had higher pain self-efficacy scores at 3 and 6 months but not at 12 months. Two of the 157 usual care participants and 12 of the 156 yoga participants reported adverse events, mostly increased pain.
LIMITATION: There were missing data for the primary outcome (yoga group, n _ 21; usual care group, n _ 18) and differential missing data (more in the yoga group) for secondary outcomes.
CONCLUSION: Offering a 12-week yoga program to adults with chronic or recurrent low back pain led to greater improvements in back function than did usual care.
KEVIN’S COMMENTS: Most people will experience low back pain at one time or another. Usually the pain can be attributed to a strained muscle or ligaments; however, persistent back pain can be caused by arthritis of the joints in the spine, bulging or ruptured discs, or pinched nerves. Serious causes of prolonged pain may include infections of the spine, fractures secondary to osteoporosis, and even cancer in the spine. Most low back pain will respond to simple rest and analgesics; however, when these measures fail, a medical evaluation is indicated to evaluate the cause and determine the most effective type of therapy.
Some persons may experience chronic and recurrent low back pain that is not related to a serious etiology, but does not respond well to simple analgesics, muscle relaxants, and exercise. This study demonstrated that a 12-week yoga program led to greater improvements in back function than usual care. Interestingly there was no significant reduction in pain noted, but the yoga group demonstrated improved confidence in performing normal activities despite pain. Current research demonstrates that pain perception is influenced not only by physical factors, but psychological and social factors as well. Effective management of persistent or recurrent pain may require the collaboration of physicians, physical and occupational therapists, psychologists and/or psychiatrists. Yoga, Tai Chi, acupuncture, cognitive behavioral therapy, guided imagery, aqua therapy, music, and relaxation exercises are among other modalities that are showing promise in the management of chronic pain. Even if pain is not significantly reduced, function may be improved as coping skills and other psychosocial factors are addressed.
Effect of 12 Months of Whole-Body Vibration Therapy on Bone Density and Structure in Postmenopausal Women: A Randomized Trial Slatkovska L, Alibhai SMH, et al. The Annals of Internal Medicine 2011; 155 (November): 668-679
BACKGROUND: Although data from studies in animals demonstrated beneficial effects of whole-body vibration (WBV) therapy on bone, clinical trials in postmenopausal women showed conflicting results.
OBJECTIVE: To determine whether WBV improves bone density and structure.
DESIGN: A 12-month, single-center, superiority, randomized, controlled trial with 3 parallel groups.
SETTING: Toronto General Hospital, Ontario, Canada.
PARTICIPANTS: Two hundred two healthy postmenopausal women with bone mineral density (BMD) T-scores between -1.0 and -2.5 who were not receiving prescription bone medications.
INTERVENTION: Participants were randomly assigned to 1 of 3 groups (1:1:1 ratio) by using a block-randomization scheme and sealed envelopes. They were asked to stand on a low magnitude (0.3g) 90-Hz or 30-Hz WBV platform for 20 minutes daily or to serve as control participants; all participants received calcium and vitamin D.
MEASUREMENTS: Bone outcome assessors, who were blinded to group assignment, determined trabecular volumetric BMD and other measurements of the distal tibia and distal radius with high resolution peripheral quantitative computed tomography and areal BMD with dual-energy x-ray absorptiometry at baseline and at 12 months.
RESULTS: Twelve months of WBV therapy had no significant effect on any bone outcomes compared with no WBV therapy. For the primary outcome of tibial trabecular volumetric BMD, mean change from baseline was 0.4 mg/cm3 (95% CI, -0.4 to 1.2 mg/cm3) in the 90-Hz WBV group, -0.1 mg/cm3 (CI, -1.0 to 0.8 mg/cm3) in the 30-Hz WBV group, and -0.2 mg/cm3 (CI, -1.1 to 0.6 mg/cm3) in the control group (P =0.55). Changes in areal BMD at the femoral neck, total hip, and lumbar spine were also similar among the groups. Overall, low-magnitude WBV at both 90 and 30-Hz was well-tolerated.
LIMITATIONS: Adherence to WBV ranged from 65% to 79%. Double-blinding was not possible.
CONCLUSION: Whole-body vibration therapy at 0.3g and 90 or 30-Hz for 12 months did not alter BMD or bone structure in postmenopausal women who received calcium and vitamin D.
KEVIN’S COMMENTS: Whole-body vibration (WBV) devices, which involve standing on a vibrating platform, are commercially available and have been extensively marketed to the public and to professionals. Animal studies suggested a favorable effect on bone density, but clinical trials in humans have shown conflicting results. This study demonstrated a lack of efficacy of WBV on bone loss in women who received calcium and vitamin D. The Food and Drug Administration has not approved WBV as a medical device, and WBV should not be recommended to prevent or treat osteoporosis.
Testing the Effect of Function-Focused Care in Assisted Living Resnick B, Galik E, et al. The Journal of the American Geriatrics Society, published online November 8, 2011
OBJECTIVES: To develop and test the Function-Focused Care in Assisted Living (FFC-AL) intervention so as to alter the decline that older adults in AL experience.
DESIGN: Cluster-randomized controlled trial using repeated measures to test the effect of FFC-AL.
SETTING: Four AL facilities with at least 100 beds.
PARTICIPANTS: One hundred seventy-one residents and 96 direct care workers (DCWs) were recruited. Ninety-five of the DCWs were female (99%), and 59 were black (62%), with a mean age of 41.7 ± 13.8. The residents were mostly female (80%), white (93%), and widowed (80%), with a mean age of 87.7 ± 5.7.
INTERVENTION: FFC-AL included four components implemented by a research-supported function focused care nurse (FFCN) and a site-identified champion over a 12-month period. Control sites were exposed to FFC education only.
MEASUREMENTS: Outcomes for residents included psychosocial domains (mood, resilience, self-efficacy, and outcome expectations for function and physical activity), function, gait and balance, and actigraphy. Outcomes for DCWs included knowledge, performance, and beliefs associated with FFC.
RESULTS: DCWs in treatment sites provided more FFC by 12 months than those in control sites. Residents in treatment sites demonstrated less decline in function, a greater percentage returned to ambulatory status, and there were positive trends demonstrating more time in moderate-level physical activity at 4 months and more overall counts of activity at 12 months than for residents in control sites.
CONCLUSION: Using a function-focused approach in AL may help prevent some of the functional decline commonly noted in these settings.
KEVIN’S COMMENTS: The culture of care in assisted living may inadvertently disempowered older adults from being physically active. Completion of tasks, such as dressing and bathing, by direct care workers (DCW) for residents who are otherwise physically capable may result in further physical decline and loss of function. The function-focused care (FFC) intervention used in this study involved an evaluation of residents’ functional capacity with an aim to help residents achieve and maintain their highest functional level and increase their time in physical activities. A primary goal was to alter how DCWs provide care to residents, so that residents could spend more time in physical activity and thus maintain and improve function.
Although the changes in care that the DCWs performed were not significantly demonstrated until 12 months after the study was initiated, the authors point out that this is consistent with previous experience with FFC interventions. It takes time to make the necessary environmental and policy-related changes, expose staff and residents to ongoing motivational interventions, and change behavior.
However, the rewards to the resident and facility can be very significant. Not only can these interventions enhance the quality of life of the resident, but it may allow them to stay in the assisted living community rather than being transferred to a higher level of care.
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