Wieland L Susan, Skoetz Nicole, Pilkington Karen, Vempati Ramaprabhu, D'Adamo Christopher R, Berman Brian M
Center for Integrative Medicine, University of Maryland School of Medicine, 520 W. Lombard Street, Baltimore, Maryland, USA, 21201.
Cochrane Haematological Malignancies Group, Department I of Internal Medicine, University Hospital of Cologne, Kerpener Str. 62, Cologne, Germany, 50937.
Cochrane Database Syst Rev. 2017 Jan 12;1(1):CD010671. doi: 10.1002/14651858.CD010671.pub2.
BACKGROUND: Non-specific low back pain is a common, potentially disabling condition usually treated with self-care and non-prescription medication. For chronic low back pain, current guidelines state that exercise therapy may be beneficial. Yoga is a mind-body exercise sometimes used for non-specific low back pain. OBJECTIVES: To assess the effects of yoga for treating chronic non-specific low back pain, compared to no specific treatment, a minimal intervention (e.g. education), or another active treatment, with a focus on pain, function, and adverse events. SEARCH METHODS: We searched CENTRAL, MEDLINE, Embase, five other databases and four trials registers to 11 March 2016 without restriction of language or publication status. We screened reference lists and contacted experts in the field to identify additional studies. SELECTION CRITERIA: We included randomized controlled trials of yoga treatment in people with chronic non-specific low back pain. We included studies comparing yoga to any other intervention or to no intervention. We also included studies comparing yoga as an adjunct to other therapies, versus those other therapies alone. DATA COLLECTION AND ANALYSIS: Two authors independently screened and selected studies, extracted outcome data, and assessed risk of bias. We contacted study authors to obtain missing or unclear information. We evaluated the overall certainty of evidence using the GRADE approach. MAIN RESULTS: We included 12 trials (1080 participants) carried out in the USA (seven trials), India (three trials), and the UK (two trials). Studies were unfunded (one trial), funded by a yoga institution (one trial), funded by non-profit or government sources (seven trials), or did not report on funding (three trials). Most trials used Iyengar, Hatha, or Viniyoga forms of yoga. The trials compared yoga to no intervention or a non-exercise intervention such as education (seven trials), an exercise intervention (three trials), or both exercise and non-exercise interventions (two trials). All trials were at high risk of performance and detection bias because participants and providers were not blinded to treatment assignment, and outcomes were self-assessed. Therefore, we downgraded all outcomes to 'moderate' certainty evidence because of risk of bias, and when there was additional serious risk of bias, unexplained heterogeneity between studies, or the analyses were imprecise, we downgraded the certainty of the evidence further.For yoga compared to non-exercise controls (9 trials; 810 participants), there was low-certainty evidence that yoga produced small to moderate improvements in back-related function at three to four months (standardized mean difference (SMD) -0.40, 95% confidence interval (CI) -0.66 to -0.14; corresponding to a change in the Roland-Morris Disability Questionnaire of mean difference (MD) -2.18, 95% -3.60 to -0.76), moderate-certainty evidence for small to moderate improvements at six months (SMD -0.44, 95% CI -0.66 to -0.22; corresponding to a change in the Roland-Morris Disability Questionnaire of MD -2.15, 95% -3.23 to -1.08), and low-certainty evidence for small improvements at 12 months (SMD -0.26, 95% CI -0.46 to -0.05; corresponding to a change in the Roland-Morris Disability Questionnaire of MD -1.36, 95% -2.41 to -0.26). On a 0-100 scale there was very low- to moderate-certainty evidence that yoga was slightly better for pain at three to four months (MD -4.55, 95% CI -7.04 to -2.06), six months (MD -7.81, 95% CI -13.37 to -2.25), and 12 months (MD -5.40, 95% CI -14.50 to -3.70), however we pre-defined clinically significant changes in pain as 15 points or greater and this threshold was not met. Based on information from six trials, there was moderate-certainty evidence that the risk of adverse events, primarily increased back pain, was higher in yoga than in non-exercise controls (risk difference (RD) 5%, 95% CI 2% to 8%).For yoga compared to non-yoga exercise controls (4 trials; 394 participants), there was very-low-certainty evidence for little or no difference in back-related function at three months (SMD -0.22, 95% CI -0.65 to 0.20; corresponding to a change in the Roland-Morris Disability Questionnaire of MD -0.99, 95% -2.87 to 0.90) and six months (SMD -0.20, 95% CI -0.59 to 0.19; corresponding to a change in the Roland-Morris Disability Questionnaire of MD -0.90, 95% -2.61 to 0.81), and no information on back-related function after six months. There was very low-certainty evidence for lower pain on a 0-100 scale at seven months (MD -20.40, 95% CI -25.48 to -15.32), and no information on pain at three months or after seven months. Based on information from three trials, there was low-certainty evidence for no difference in the risk of adverse events between yoga and non-yoga exercise controls (RD 1%, 95% CI -4% to 6%).For yoga added to exercise compared to exercise alone (1 trial; 24 participants), there was very-low-certainty evidence for little or no difference at 10 weeks in back-related function (SMD -0.60, 95% CI -1.42 to 0.22; corresponding to a change in the Oswestry Disability Index of MD -17.05, 95% -22.96 to 11.14) or pain on a 0-100 scale (MD -3.20, 95% CI -13.76 to 7.36). There was no information on outcomes at other time points. There was no information on adverse events.Studies provided limited evidence on risk of clinical improvement, measures of quality of life, and depression. There was no evidence on work-related disability. AUTHORS' CONCLUSIONS: There is low- to moderate-certainty evidence that yoga compared to non-exercise controls results in small to moderate improvements in back-related function at three and six months. Yoga may also be slightly more effective for pain at three and six months, however the effect size did not meet predefined levels of minimum clinical importance. It is uncertain whether there is any difference between yoga and other exercise for back-related function or pain, or whether yoga added to exercise is more effective than exercise alone. Yoga is associated with more adverse events than non-exercise controls, but may have the same risk of adverse events as other back-focused exercise. Yoga is not associated with serious adverse events. There is a need for additional high-quality research to improve confidence in estimates of effect, to evaluate long-term outcomes, and to provide additional information on comparisons between yoga and other exercise for chronic non-specific low back pain.
背景:非特异性下腰痛是一种常见的、可能导致残疾的疾病,通常采用自我护理和非处方药进行治疗。对于慢性下腰痛,当前指南指出运动疗法可能有益。瑜伽是一种身心锻炼方式,有时用于治疗非特异性下腰痛。 目的:评估瑜伽治疗慢性非特异性下腰痛的效果,与无特定治疗、最小干预(如教育)或其他积极治疗相比,重点关注疼痛、功能和不良事件。 检索方法:我们检索了截至2016年3月11日的CENTRAL、MEDLINE、Embase、其他五个数据库和四个试验注册库,不受语言或出版状态的限制。我们筛选了参考文献列表并联系了该领域的专家以识别其他研究。 选择标准:我们纳入了慢性非特异性下腰痛患者的瑜伽治疗随机对照试验。我们纳入了比较瑜伽与任何其他干预或无干预的研究。我们还纳入了比较瑜伽作为其他疗法辅助手段与单独使用其他疗法的研究。 数据收集与分析:两位作者独立筛选和选择研究,提取结局数据,并评估偏倚风险。我们联系研究作者以获取缺失或不清楚的信息。我们使用GRADE方法评估证据的总体确定性。 主要结果:我们纳入了在美国(7项试验)、印度(3项试验)和英国(2项试验)进行的12项试验(1080名参与者)。研究无资金支持(1项试验)、由瑜伽机构资助(1项试验)、由非营利或政府来源资助(7项试验)或未报告资金情况(3项试验)。大多数试验使用艾扬格瑜伽、哈他瑜伽或维尼瑜伽形式。试验将瑜伽与无干预或非运动干预(如教育)(7项试验)、运动干预(3项试验)或运动和非运动干预(2项试验)进行了比较。所有试验均存在较高的实施和检测偏倚风险,因为参与者和提供者未对治疗分配进行盲法,且结局为自我评估。因此,由于偏倚风险,我们将所有结局降级为“中等”确定性证据,当存在额外的严重偏倚风险、研究间无法解释的异质性或分析不精确时,我们进一步降低证据的确定性。 与非运动对照相比的瑜伽(9项试验;810名参与者),有低确定性证据表明瑜伽在三到四个月时对背部相关功能产生小到中等程度的改善(标准化均值差(SMD)-0.40,95%置信区间(CI)-0.66至-0.14;相当于罗兰-莫里斯残疾问卷中平均差(MD)-2.18,95%-3.60至-0.76的变化),有中等确定性证据表明在六个月时产生小到中等程度的改善(SMD -0.44,95% CI -0.66至-0.22;相当于罗兰-莫里斯残疾问卷中MD -2.15,95%-3.23至-1.08的变化),有低确定性证据表明在12个月时产生小的改善(SMD -0.26,95% CI -0.46至-0.05;相当于罗兰-莫里斯残疾问卷中MD -1.36,95%-2.41至-0.26的变化)。在0-100分的量表上,有非常低到中等确定性证据表明瑜伽在三到四个月(MD -4.55,95% CI -7.04至-2.06)、六个月(MD -7.81,95% CI -13.37至-2.25)和12个月(MD -5.40,95% CI -14.50至-3.70)时对疼痛的改善略好,然而我们预先定义的疼痛临床显著变化为15分或更高,且未达到该阈值。根据六项试验的信息,有中等确定性证据表明瑜伽组不良事件的风险,主要是背痛增加,高于非运动对照组(风险差(RD)5%,95% CI 2%至8%)。 与非瑜伽运动对照相比的瑜伽(4项试验;394名参与者),有非常低确定性证据表明在三个月时背部相关功能几乎没有差异(SMD -0.22,95% CI -0.65至0.20;相当于罗兰-莫里斯残疾问卷中MD -0.99,95%-2.87至0.90的变化)和六个月时(SMD -0.20,95% CI -0.59至0.19;相当于罗兰-莫里斯残疾问卷中MD -0.90,95%-2.61至0.81的变化),且六个月后无背部相关功能的信息。有非常低确定性证据表明在七个月时0-100分量表上的疼痛较低(MD -20.40,95% CI -25.48至-15.32),且三个月或七个月后无疼痛信息。根据三项试验的信息,有低确定性证据表明瑜伽与非瑜伽运动对照组之间不良事件风险无差异(RD 1%,95% CI -4%至6%)。 与单独运动相比,瑜伽加运动(1项试验;24名参与者),有非常低确定性证据表明在10周时背部相关功能(SMD -0.60,95% CI -1.42至0.22;相当于奥斯威斯残疾指数中MD -17.05,95%-22.96至11.14的变化)或0-100分量表上的疼痛(MD -3.20,95% CI -13.76至7.36)几乎没有差异。其他时间点无结局信息。无不良事件信息。 研究提供了关于临床改善风险、生活质量测量和抑郁的有限证据。无关于工作相关残疾的证据。 作者结论:有低到中等确定性证据表明,与非运动对照相比,瑜伽在三到六个月时可使背部相关功能产生小到中等程度的改善。瑜伽在三到六个月时对疼痛可能也略更有效,然而效应大小未达到预先定义的最小临床重要性水平。瑜伽与其他运动在背部相关功能或疼痛方面是否存在差异,或瑜伽加运动是否比单独运动更有效尚不确定。与非运动对照相比,瑜伽与更多不良事件相关,但可能与其他针对背部的运动有相同的不良事件风险。瑜伽与严重不良事件无关。需要更多高质量研究来提高对效应估计的信心,评估长期结局,并提供关于瑜伽与其他运动治疗慢性非特异性下腰痛比较的更多信息。
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