对于背痛 瑜珈效果和物理治疗一样好

新研究显示,对于美国最常见的疼痛问题-慢性下背痛,瑜珈的缓解效果和物理治疗一样好。

  【24drs.com】波士顿医学中心整合医学主任Robert B. Saper医师表示,长期进行瑜珈者的效果最明显;Saper医师在美国疼痛管理学院2016年会发表他的研究结果。
  
  之前的研究显示,瑜珈可改善疼痛与功能、减少药物使用,研究也显示,物理治疗(PT)可有效治疗背痛患者。
  
  Saper医师表示,我们知道瑜珈有效、PT有效,但是我们不知道它们的效果比较。为了将辅助健康做法纳入主流医疗保健,我会说(至少)它必须像常规治疗一样有效,且或许可提供其它好处,如成本效益。
  
  为了这项新研究,研究者从波士顿地区的社区健康中心纳入320名无明显解剖原因,如脊柱狭窄的慢性背痛成年患者。Saper医师表示,患者有相当高的疼痛分数(10分疼痛量表测试,平均7分) 以及相当不稳定的背痛,几乎有四分之三曾使用止痛药物,约20%服用鸦片类止痛剂。
  
  他表示,进行这篇研究时,我们绝对没有招纳患者的问题;这是因为人们患有慢性疼痛,而他们的需求没有得到满足。
  
  这些患者被随机分组到以下三组之一:瑜珈、PT或卫教。
  
  瑜珈组提供每周一次的75分钟课程,采用师生比率相当低的指导方式。课程从一段关于瑜珈哲学(非暴力、适度、自我接受)的短片开始,然后提供瑜珈垫给这些参与者做一些简单的瑜珈姿势,他们也收到一片DVD,让他们可以在家看着练习。
  
  Saper医师表示,有些患者确实有困难,特别是那些肥胖者,但是,这些课程进度慢且温和;第一堂课可能只是让人躺在地板、膝胸式、或桌面式。
  
  PT组有15次一对一的60分钟课程,包括有氧运动;卫教组则是获得一本关于腰痛的综合性书籍。
  
  PT组和瑜珈组课程都持续12周,之后追踪患者到52周。此时,PT组和瑜珈组的患者都被随机指定维持(参加瑜珈课程或更多PT课程)或只是在家练习。
  
  研究显示,PT组和瑜珈组报告了相同的功能,Saper医师表示,他们和12周的卫教没有很大差异。
  
  但是,整体而言,患者没有参加太多瑜珈课程或PT课程-第一阶段约7堂。Saper医师表示,看看那些真正去参加瑜珈课程的患者,你发现瑜珈和PT仍颇为相似,与教育的区别仍是相当高的。
  
  对于疼痛评分也有相似的结果。
  
  Saper医师表示,PT组和瑜珈组报告表示「极有改善」与「非常满意」的患者人数相当。
  
  瑜珈证明是安全的,只有轻微且通常是暂时性的恶化背痛。
  
  Saper医师表示,除了低遵从率,本研究的另一个限制是,这是一个非常结构化的标准化瑜珈课程,我们不知道患者如果去街上的瑜珈教室时会如何进行。
  
  他表示,需要更大型的研究来发展更佳的方式,以确保研究对象遵守研究指引。
  
  Saper医师表示,研究者目前将分析瑜珈的相关费用。
  
  同样也参与研讨会发表、国家健康研究院辅助与整合健康中心的M. Catherine Bushnell博士表示,有证据显示,瑜珈对脑部有正面影响。她表示,一个人做多久的瑜珈和脑部的正面改变之间似乎有著相当强大的关系。
  
  资料来源:http://www.24drs.com/
  
  Native link:Yoga as Good as Physical Therapy for Back Pain

Yoga as Good as Physical Therapy for Back Pain

By Pauline Anderson
Medscape Medical News

SAN ANTONIO — Yoga is as good as physical therapy (PT) in reducing chronic low back pain, the most common pain problem in the United States, new research shows.

"Our study showed that yoga was noninferior to physical therapy for a diverse group of low-income patients," said Robert B. Saper, MD, director of integrative medicine, Boston Medical Center, Massachusetts. "Its effectiveness was most obvious in the most adherent patients."

Dr Saper presented his study at the American Academy of Pain Management (AAPM) 2016 Annual Meeting. The AAPM recently changed its name to the Academy of Integrative Pain Management.

Previous research has shown that yoga improves pain and function and reduces medication use. For example, a 2013 meta-analysis demonstrated small to medium effect sizes for yoga in short-term and long-term back pain–related disability. Research also shows that PT is effective in treating patients with back pain.

"We know that yoga is effective, we know that PT is effective, but we don't know their comparative effectiveness," said Dr Saper. "To get a complementary health practice into mainstream healthcare, I would say that a minimal bar is that it has to be as effective as the conventional therapy, and perhaps offer other benefits, like cost-effectiveness."

PT is considered a conventional therapy and is the most common nonpharmacologic referral by physicians for chronic low back pain, Dr Saper said. About 22% of patients with low back pain in primary care get referred for PT.

For this new study, researchers enrolled 320 adult patients from Boston-area community health centers who had chronic back pain with no obvious anatomic cause, such as spinal stenosis. The patients were predominantly nonwhite and low income, with a relatively low education level.

The patients had "quite high" pain scores (average of 7 out of 10 on a pain scale) and were "quite disabled" in terms of their back pain, said Dr Saper. Almost three quarters were using pain medication, with about 20% taking opioids.

"We had absolutely no problem recruiting patients" for this study, said Dr Saper. "That's because people are suffering with chronic pain and their needs are not being met."

Patients were randomly assigned to one of three groups: yoga, PT, or education.

To develop the structured yoga protocol, Dr Saper and his colleagues organized an expert panel, which reviewed the literature on the topic. The final product was a 75-minute weekly class with a very low student-to-teacher ratio.

The classes began with short segment on yoga philosophy (nonviolence, moderation, self-acceptance). Participants were then given mats on which to do the simple yoga poses. They received a DVD to practice these at home.

Fear of Injury

Asked by a delegate how he encouraged patients with pain to get down on the floor when many are afraid of injury, Dr Saper said that some patients did have difficulty, especially those who were obese. "But these classes go slow and gentle; the first class may be just getting people on the floor, knees to chest, or in a table position."

The PT group had 15 one-on-one 60-minute sessions that included aerobic exercise. PT personnel were trained to help coach patients on fear avoidance.

The education group got a comprehensive book on back pain.

Both the PT and yoga sessions continued for 12 weeks, after which patients were followed to 52 weeks. During this postintervention period, patients in both the yoga and PT groups were randomly assigned to maintenance (drop in yoga classes or more PT sessions) or just at-home practice.

Overall adherence was not great. The mean number of yoga classes and PT sessions attended during the initial phase was 7.

The primary question being addressed was whether yoga is not inferior to PT at 12 weeks.

The study showed that for function (score on the Roland-Morris Disability Questionnaire), yoga and PT "are exactly the same, ie noninferior," said Dr Saper, adding that, "they are not terribly different from education at 12 weeks."

However, looking at just those patients who actually went to the yoga classes, he said, "you see yoga and PT are still quite similar, but the difference with education is quite high."

There were similar results for pain scores. "You see that yoga and PT are essentially the same: a little bit better than education, but much better when you look at the per protocol analysis."

As for the percentage of participants who had at least a 30% reduction, "if you look at Roland [Morris Disability Questionnaire], it's 48% for yoga, 37% for PT, and 23% for education," said Dr Saper. "What that means is that for every two patients who go to yoga, about 50% of them are going to have a clinical response."

Looking at odds ratios for function, comparing the various interventions, "yoga is actually superior" to PT and is "quite a bit" superior to education, said Dr Saper.

At baseline, about 70% of participants were using medication. At 12 weeks, such use was down by about 20% in both the yoga and PT groups, and hadn't changed in the education group.

A similar number of yoga and PT subjects reported being "very improved" and "very satisfied," said Dr Saper.

Yoga proved to be safe, with only mild, usually transient exacerbations of back pain.

In addition to the low adherence rate, another possible limitation of the study is that its findings may not be generalizable. "This was a very structured standardized yoga program," said Dr Saper. "We don't know how patients will do if they go to the yoga studio down the street."

Larger studies are needed to develop better strategies to enhance adherence, he said.

Cost-Effectiveness

Researchers will now analyze costs involved with yoga, Dr Saper told Medscape Medical News after his presentation.

"We are collecting data to assess the cost-effectiveness of yoga for clinical back pain, from the perspective of the payer, society and the patient. We will see what those analyses show; potentially it will justify, in combination with the efficacy data, coverage by hospital or a payer system for structured yoga programs."

Asked to comment on this new study, Robert Bonakdar, MD, Scripps Center for Integrative Medicine, La Jolla, California, said it's asking "an important question:" how something "new and upcoming like yoga" compares to a standard therapy.

"Every family physician, every front line physician, with low back pain patients is looking at nonpharmacological care, and one of the initial things is physical therapy. But unfortunately, this does not work in all pain patients."

In some cases, said Dr Bonakdar, PT may not be accessible or covered by insurance, in which case it can be prohibitively expensive. Alternatively, "there are yoga classes that cost $10 or $15 a week," said Dr Bonakdar, and yoga "can be transitioned into a home practice."

The new study "adds to our knowledge in suggesting that a) yoga is as good as the standard of care, non pharmacologic therapy, and b) it can be done in a diverse population, including a low income, non-English speaking population in Boston. So it takes away some of those barriers to recommending it."

The beauty of yoga, said Dr Bonakdar, is that "it's very well packaged" and includes not only body awareness, but mind awareness and breathing awareness. "And it feels good to do it; you don't feel like you're doing a medical intervention."

There's also evidence that yoga has a positive impact on the brain. According to M. Catherine Bushnell, PhD, National Center for Complementary and Integrative Health, National Institutes of Health, long-time yoga practitioners have more gray matter than matched physically active controls.

"Gray matter goes down with age, but yoga practitioners have a flat line; you don't see this age-related decrease in gray matter that you see in other healthy people," Dr Bushnell told delegates during a separate plenary presentation.

And there seems to be "quite a robust" relationship between how long a person has done yoga and positive brain changes, she said. "The number of years a person has practiced yoga, the more gray matter at multiple sites in the brain."

Yoga influences areas of the brain that are important for pain modulation, said Dr Bushnell.

It is a "complex activity" that involves not only exercise but also breath control and meditation. And although analyses show that exercise is the biggest contributor to gray matter, all the other elements of yoga also play a role, she said.

Another study cited by Dr Bushnell measured the amount of time participants could keep their hand in cold water. It showed that yoga practitioners have a higher pain tolerance than other people.

In one area of the brain — the insula cortex — there was a relationship between pain tolerance and amount of gray matter, she said.

The study was supported by a grant from the National Center for Complementary and Integrative Health. Dr Saper and Dr Bushnell have disclosed no relevant financial relationships. . Dr Bushnell's views are her own and do not reflect the position or policy of the National Institutes of Health, the Public Health Service, or the US Department of Health and Human Services.

American Academy of Pain Management (AAPM) 2016 Annual Meeting. Presented September 23, 24, 2016.

    
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