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Can Yoga or Physical Therapy for Chronic Low Back Pain Improve Depression and Anxiety Among Adults From a Racially Diverse, Low-Income Community? A Secondary Analysis of a Randomized Controlled Trial

  • Christopher Joyce
    Correspondence
    Corresponding author Christopher Joyce, DPT, PhD, School of Physical Therapy, Massachusetts College of Pharmacy and Health Sciences, 10 Lincoln Square, Worcester, MA, 01608.
    Affiliations
    Department of Rehabilitation Science, Massachusetts General Hospital Institute of Health Professions, Boston, Massachusetts, United States

    School of Physical Therapy, Massachusetts College of Pharmacy and Health Sciences University, Worcester, Massachusetts, United States
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  • Eric J. Roseen
    Affiliations
    Department of Rehabilitation Science, Massachusetts General Hospital Institute of Health Professions, Boston, Massachusetts, United States

    Department of Family Medicine, Boston University School of Medicine and Boston Medical Center, Boston, Massachusetts, United States
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  • Julie J. Keysor
    Affiliations
    Department of Rehabilitation Science, Massachusetts General Hospital Institute of Health Professions, Boston, Massachusetts, United States

    Department of Physical Therapy, Massachusetts General Hospital Institute of Health Professions, Boston, Massachusetts, United States
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  • K. Douglas Gross
    Affiliations
    Department of Rehabilitation Science, Massachusetts General Hospital Institute of Health Professions, Boston, Massachusetts, United States

    Department of Physical Therapy, Massachusetts General Hospital Institute of Health Professions, Boston, Massachusetts, United States
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  • Larry Culpepper
    Affiliations
    Department of Family Medicine, Boston University School of Medicine and Boston Medical Center, Boston, Massachusetts, United States
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  • Robert B. Saper
    Affiliations
    Department of Family Medicine, Boston University School of Medicine and Boston Medical Center, Boston, Massachusetts, United States
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Published:February 05, 2021DOI:https://doi.org/10.1016/j.apmr.2021.01.072

      Highlights

      • Depression and anxiety are common in low-income and minority groups with chronic low back pain.
      • Physical therapy and yoga for chronic low back pain may improve symptoms of comorbid depression and anxiety.
      • Improvement in back-related function is associated with an improvement in depressive symptoms.

      Abstract

      Objective

      To determine and compare the effect of yoga, physical therapy (PT), and education on depressive and anxious symptoms in patients with chronic low back pain (CLBP).

      Design

      Secondary analysis of a randomized controlled trial.

      Setting

      Academic safety net hospital and 7 community health centers.

      Participants

      A total of 320 adults with CLBP.

      Intervention

      Yoga classes, PT sessions, or an educational book.

      Outcome Measure

      Depression and anxiety were measured using the Patient Health Questionnaire and Generalized Anxiety Disorder 7-item Scale, respectively, at baseline, 12, and 52 weeks. We identified baseline and midtreatment (6-wk) factors associated with clinically meaningful improvements in depressive (≥3 points) or anxious (≥2 points) symptoms at 12 weeks.

      Results

      Participants (female=64%; mean age, 46.0±10.7 years) were predominantly non-White (82%), low-income (<$30,000/year, 59%), and had not received a college degree (71%). Most participants had mild or worse depressive (60%) and anxious (50%) symptoms. At 12 weeks, yoga and PT participants experienced modest within-group improvements in depressive symptoms (mean difference [MD]=−1.23 [95% CI, −2.18 to −0.28]; MD=−1.01 [95% CI, −2.05 to −0.03], respectively). Compared with the education group, 12-week differences were not statistically significant, although trends favored yoga (MD=−0.71 [95% CI, −2.22 to 0.81]) and PT (MD= −0.32 [95% CI, −1.82 to 1.18]). At 12 weeks, improvements in anxious symptoms were only found in participants who had mild or moderate anxiety at baseline. Independent of treatment arm, participants who had 30% or greater improvement in pain or function midtreatment were more likely to have a clinically meaningful improvement in depressive symptoms (odds ratio [OR], 1.82 [95% CI, 1.03-3.22]; OR, 1.79 [95% CI, 1.06-3.04], respectively).

      Conclusions

      In our secondary analysis we found that depression and anxiety, common in this sample of underserved adults with CLBP, may improve modestly with PT and yoga. However, effects were not superior to education. Improvements in pain and function are associated with a decrease in depressive symptoms. More research is needed to optimize the integration of physical and psychological well-being in PT and yoga.

      Keywords

      List of abbreviations:

      CLBP (chronic low back pain), GAD-7 (Generalized Anxiety Disorder 7-item Scale), MCID (minimal clinically important difference), MD (mean difference), NRS (numeric rating scale), OR (odds ratio), PHQ-8 (Patient Health Questionnaire 8), PT (physical therapy), RMDQ (Roland Morris Disability Questionnaire)
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      References

        • Vos T.
        • Allen C.
        • Arora M.
        • et al.
        Global, regional, and national incidence, prevalence, and years lived with disability for 310 diseases and injuries, 1990–2015: a systematic analysis for the Global Burden of Disease Study 2015.
        Lancet. 2016; 388: 1545-1602
        • World Health Organization
        Depression and other common mental disorders: global health estimates.
        World Heal Organ. 2017; : 1-24
        • Bloom D.
        • Cafiero E.
        • Jané-Llopis E.
        • et al.
        The global economic burden of noncommunicable diseases.
        Program on the Global Demography of Aging, World Economic Forum, Geneva2011
        • Wong A.Y.
        • Karppinen J.
        • Samartzis D.
        Low back pain in older adults: risk factors, management options and future directions.
        Scoliosis Spinal Disord. 2017; 12: 14
        • Institute of Medicine
        Relieving pain in America: a blueprint for transforming prevention, care, education, and research.
        National Academies Press, Washington (DC)2011
        • Hudson C.G.
        Socioeconomic status and mental illness: tests of the social causation and selection hypotheses.
        Am J Orthopsychiatry. 2005; 75: 3-18
        • Green M.J.
        • Benzeval M.
        The development of socioeconomic inequalities in anxiety and depression symptoms over the lifecourse.
        Soc Psychiatry Psychiatr Epidemiol. 2013; 48: 1951-1961
        • Freeman A.
        • Tyrovolas S.
        • Koyanagi A.
        • et al.
        The role of socio-economic status in depression: results from the COURAGE (aging survey in Europe).
        BMC Public Health. 2016; 16: 1098
        • Gore M.
        • Sadosky A.
        • Stacey B.R.
        • Tai K.S.
        • Leslie D.
        The burden of chronic low back pain.
        Spine (Phila Pa 1976). 2012; 37: E668-E677
        • Arnow B.A.
        • Hunkeler E.M.
        • Blasey C.M.
        • et al.
        Comorbid depression, chronic pain, and disability in primary care.
        Psychosom Med. 2006; 68: 262-268
        • Kroenke K.
        • Wu J.
        • Bair M.J.
        • Krebs E.E.
        • Damush T.M.
        • Tu W.
        Reciprocal relationship between pain and depression: a 12-month longitudinal analysis in primary care.
        J Pain. 2011; 12: 964-973
        • Louw A.
        • Diener I.
        • Butler D.S.
        • Puentedura E.J.
        The effect of neuroscience education on pain, disability, anxiety, and stress in chronic musculoskeletal pain.
        Arch Phys Med Rehabil. 2011; 92: 2041-2056
        • Qaseem A.
        • Wilt T.J.
        • McLean R.M.
        • Forciea M.A.
        Noninvasive treatments for acute, subacute, and chronic low back pain: a clinical practice guideline from the American College of Physicians.
        Ann Intern Med. 2017; 166: 514-530
        • Foster N.E.
        • Anema J.R.
        • Cherkin D.
        • et al.
        Prevention and treatment of low back pain: evidence, challenges, and promising directions.
        Lancet. 2018; 6736: 1-16
        • Wieland L.S.
        • Skoetz N.
        • Pilkington K.
        • Vempati R.
        • D’Adamo C.R.
        • Berman B.M.
        Yoga treatment for chronic non-specific low back pain.
        Cochrane Database Syst Reve. 2017; 1: CD010671
        • Hofmann S.G.
        • Andreoli G.
        • Carpenter J.K.
        • Curtiss J.
        Effect of hatha yoga on anxiety: a meta-analysis.
        J Evid Based Med. 2016; 9: 116-124
        • Cramer H.
        • Lauche R.
        • Langhorst J.
        • Dobos G.
        Yoga for depression: a systematic review and meta-analysis.
        Depress Anxiety. 2013; 30: 1068-1083
        • Bridges L.
        • Sharma M.
        The efficacy of yoga as a form of treatment for depression.
        J Evid Based Complementary Altern Med. 2017; 22: 1017-1028
        • Prathikanti S.
        • Rivera R.
        • Cochran A.
        • Tungol J.G.
        • Fayazmanesh N.
        • Weinmann E.
        Treating major depression with yoga: a prospective, randomized, controlled pilot trial.
        PLoS One. 2017; 12: 1-36
        • Wideman T.H.
        • Scott W.
        • Martel M.O.
        • Sullivan M.J.L.
        Recovery from depressive symptoms over the course of physical therapy: a prospective cohort study of individuals with work-related orthopaedic injuries and symptoms of depression.
        J Orthop Sport Phys Ther. 2012; 42: 957-967
        • Sullivan M.J.L.
        • Adams H.
        Psychosocial treatment techniques to augment the impact of physiotherapy interventions for low back pain.
        Physiother Can. 2010; 62: 180-189
        • Saper R.B.
        • 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
        • Saper R.B.
        • Sherman K.J.
        • Delitto A.
        • et al.
        Yoga vs. physical therapy vs. education for chronic low back pain in predominantly minority populations: study protocol for a randomized controlled trial.
        Trials. 2014; 15: 1-21
        • Saper R.B.
        • Boah A.R.
        • Keosaian J.
        • Cerrada C.
        • Weinberg J.
        • Sherman K.J.
        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: 658030
        • Fritz J.M.
        • Cleland J.A.
        • Childs J.D.
        Subgrouping patients with low back pain: evolution ofa classification approach to physical therapy.
        J Orthop Sport Phys Ther. 2007; 37: 290-302
        • Roland M.
        • Waddell G.
        • Klaber Moffett J.
        • Burton K.
        • Main C.
        The back book.
        Sationary Office Books, Norwich, UK2002
        • Moore J.
        • Lorig K.
        • Van Korff M.
        • Gonzalez V.
        • Laurent D.D.
        The back pain help book. Perseus ed.
        ABC-CLIO, LLC, Reading, MA1999
        • Schuch F.B.
        • Vancampfort D.
        • Richards J.
        • Rosenbaum S.
        • Ward P.B.
        • Stubbs B.
        Exercise as a treatment for depression: a meta-analysis adjusting for publication bias.
        J Psychiatr Res. 2016; 77: 42-51
        • Stubbs B.
        • Vancampfort D.
        • Rosenbaum S.
        • et al.
        An examination of the anxiolytic effects of exercise for people with anxiety and stress-related disorders: a meta-analysis.
        Psychiatry Res. 2017; 249: 102-108
        • de Souza Moura A.M.
        • Lamego M.K.
        • Paes F.
        • et al.
        Comparison among aerobic exercise and other types of interventions to treat depression: a systematic review.
        CNS Neurol Disord Drug Targets. 2015; 14: 1171-1183
      1. Depression in adults: recognition and management. National Institute for Health and Care Excellence (UK), London2009
        • Goyal M.
        • Singh S.
        • Sibinga E.M.S.
        • et al.
        Meditation programs for psychological stress and well-being: a systematic review and meta-analysis.
        JAMA Intern Med. 2014; 174: 357-368
        • Kroenke K.
        • Spitzer R.L.
        • Williams J.B.W.
        The PHQ-9.
        J Gen Intern Med. 2001; 16: 606-613
        • Kroenke K.
        • Strine T.W.
        • Spitzer R.L.
        • Williams J.B.W.
        • Berry J.T.
        • Mokdad A.H.
        The PHQ-8 as a measure of current depression in the general population.
        J Affect Disord. 2009; 114: 163-173
        • Wu Y.
        • Levis B.
        • Riehm K.E.
        • et al.
        Equivalency of the diagnostic accuracy of the PHQ-8 and PHQ-9: a systematic review and individual participant data meta-analysis.
        Psychol Med. 2020; 50: 1368-1380
        • Gilbody S.
        • Richards D.
        • Brealey S.
        • Hewitt C.
        Screening for depression in medical settings with the Patient Health Questionnaire (PHQ): a diagnostic meta-analysis.
        J Gen Intern Med. 2007; 22: 1596-1602
        • Huang F.Y.
        • Chung H.
        • Kroenke K.
        • Delucchi K.L.
        • Spitzer R.L.
        Using the Patient Health Questionnaire-9 to measure depression among racially and ethnically diverse primary care patients.
        J Gen Intern Med. 2006; 21: 547-552
        • Manea L.
        • Gilbody S.
        • McMillan D.
        Optimal cut-off score for diagnosing depression with the Patient Health Questionnaire (PHQ-9): a meta-analysis.
        CMAJ. 2012; 184: E191-E196
        • Titov N.
        • Dear B.F.
        • McMillan D.
        • Anderson T.
        • Zou J.
        • Sunderland M.
        Psychometric comparison of the PHQ-9 and BDI-II for measuring response during treatment of depression.
        Cogn Behav Ther. 2011; 40: 126-136
        • Kroenke K.
        • Wu J.
        • Yu Z.
        • et al.
        Patient Health Questionnaire Anxiety and Depression Scale: initial validation in three clinical trials.
        Psychosom Med. 2016; 78: 716-727
        • Spitzer R.L.
        • Kroenke K.
        • Williams J.B.W.
        • Löwe B.
        A brief measure for assessing generalized anxiety disorder.
        Arch Intern Med. 2006; 166: 1092
        • Seo J.G.
        • Park S.P.
        Validation of the Generalized Anxiety Disorder-7 (GAD-7) and GAD-2 in patients with migraine.
        J Headache Pain. 2015; 16: 1-7
        • Kroenke K.
        • Spitzer R.L.
        • Williams J.B.W.
        • Monahan P.O.
        • Löwe B.
        Anxiety disorders in primary care: prevalence, impairment, comorbidity, and detection.
        Ann Intern Med. 2007; 146: 317
        • Kroenke K.
        • Spitzer R.L.
        • Williams J.B.W.
        • Löwe B.
        The Patient Health Questionnaire Somatic, Anxiety, and Depressive Symptom Scales: a systematic review.
        Gen Hosp Psychiatry. 2010; 32: 345-359
        • Dear B.F.
        • Titov N.
        • Sunderland M.
        • et al.
        Psychometric comparison of the Generalized Anxiety Disorder Scale-7 and the Penn State Worry Questionnaire for measuring response during treatment of Generalised Anxiety Disorder.
        Cogn Behav Ther. 2011; 40: 216-227
        • Ritter P.L.
        • González V.M.
        • Laurent D.D.
        • Lorig K.R.
        Measurement of pain using the visual numeric scale.
        J Rheumatol. 2006; 33: 574-580
        • Roland M.
        • Fairbank J.
        The Roland-Morris Disability Questionnaire and the Oswestry Disability Questionnaire.
        Spine (Phila Pa 1976). 2000; 25: 3115-3124
        • Waddell G.
        • Newton M.
        • Henderson I.
        • Somerville D.
        • Main C.J.
        A Fear-Avoidance Beliefs Questionnaire (FABQ) and the role of fear-avoidance beliefs in chronic low back pain and disability.
        Pain. 1993; 52: 157-168
        • Anderson K.O.
        • Dowds B.N.
        • Pelletz R.E.
        • Edwards W.T.
        • Peeters-Asdourian C.
        Development and initial validation of a scale to measure self-efficacy beliefs in patients with chronic pain.
        Pain. 1995; 63: 77-84
        • Ostelo R.W.
        • Deyo R.A.
        • Stratford P.
        • et al.
        Interpreting change scores for pain and functional status in low back pain: towards international consensus regarding minimal important change.
        Spine (Phila Pa 1976). 2008; 33: 90-94
        • Jordan K.
        • Dunn K.M.
        • Lewis M.
        • Croft P.
        A minimal clinically important difference was derived for the Roland-Morris Disability Questionnaire for low back pain.
        J Clin Epidemiol. 2006; 59: 45-52
        • Newman D.A.
        Missing data: five practical guidelines.
        Organ Res Methods. 2014; 17: 372-411
        • Asmundson G.J.G.
        • Katz J.
        Understanding the co-occurrence of anxiety disorders and chronic pain: state-of-the-art.
        Depress Anxiety. 2009; 26: 888-901
        • Miller L.R.
        • Cano A.
        Comorbid chronic pain and depression: who is at risk?.
        J Pain. 2009; 10: 619-627
        • Sagheer M.A.
        • Khan M.F.
        • Sharif S.
        Association between chronic low back pain, anxiety and depression in patients at a tertiary care centre.
        J Pak Med Assoc. 2013; 63: 688-690
        • Currie S.R.
        • Wang J.L.
        Chronic back pain and major depression in the general Canadian population.
        Pain. 2004; 107: 54-60
        • Han C.
        • Pae C.U.
        Pain and depression: a neurobiological perspective of their relationship.
        Psychiatry Investig. 2015; 12: 1-8
        • Kroenke K.
        • Shen J.
        • Oxman T.E.
        • Williams J.W.
        • Dietrich A.J.
        Impact of pain on the outcomes of depression treatment: results from the RESPECT trial.
        Pain. 2008; 134: 209-215
        • Simons L.E.
        • Elman I.
        • Borsook D.
        Psychological processing in chronic pain: a neural systems approach.
        Neurosci Biobehav Rev. 2014; 39: 61-78
        • Mikkelsen K.
        • Stojanovska L.
        • Polenakovic M.
        • Bosevski M.
        • Apostolopoulos V.
        Exercise and mental health.
        Maturitas. 2017; 106: 48-56
        • Oliveira C.B.
        • Maher C.G.
        • Pinto R.Z.
        • et al.
        Clinical practice guidelines for the management of non-specific low back pain in primary care: an updated overview.
        Eur Spine J. 2018; 27: 1-13
        • Pinheiro M.B.
        • Ferreira M.L.
        • Refshauge K.
        • et al.
        Symptoms of depression as a prognostic factor for low back pain: a systematic review.
        Spine J. 2016; 16: 105-116
        • Tsuji T.
        • Matsudaira K.
        • Sato H.
        • Vietri J.
        The impact of depression among chronic low back pain patients in Japan.
        BMC Musculoskelet Disord. 2016; 17: 1-9
        • Brunner E.
        • Dankaerts W.
        • Meichtry A.
        • O’Sullivan K.
        • Probst M.
        Physical therapists’ ability to identify psychological factors and their self-reported competence to manage chronic low back pain.
        Phys Ther. 2018; 98: 471-479
        • Beales D.
        • Kendell M.
        • Chang R.P.
        • et al.
        Association between the 10 item Örebro Musculoskeletal Pain Screening Questionnaire and physiotherapists’ perception of the contribution of biopsychosocial factors in patients with musculoskeletal pain.
        Man Ther. 2016; 23: 48-55
        • Fay P.
        • Edmond S.L.
        • Baron J.K.
        • Joshi M.
        Depression screening by physical therapists: practices, beliefs, barriers.
        J Back Musculoskelet Rehabil. 2017; 30: 1221-1229
        • Synnott A.
        • O’Keeffe M.
        • Bunzli S.
        • Dankaerts W.
        • O’Sullivan P.
        • O’Sullivan K.
        Physiotherapists may stigmatise or feel unprepared to treat people with low back pain and psychosocial factors that influence recovery: a systematic review.
        J Physiother. 2015; 61: 68-76
        • Manzoni G.M.
        • Pagnini F.
        • Castelnuovo G.
        • Molinari E.
        Relaxation training for anxiety: a ten-years systematic review with meta-analysis.
        BMC Psychiatry. 2008; 8: 41
        • Berlowitz J.
        • Hall D.L.
        • Joyce C.
        • et al.
        Changes in perceived stress after yoga, physical therapy, and education interventions for chronic low back pain: a secondary analysis of a randomized controlled trial.
        Pain Med. 2020; 21: 2529-2537
        • Roseen E.J.
        • Gerlovin H.
        • Femia A.
        • et al.
        Yoga, physical therapy, and back pain education for sleep quality in low-income racially diverse adults with chronic low back pain: a secondary analysis of a randomized controlled trial.
        J Gen Intern Med. 2020; 35: 167-176