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

  • Eric J. RoseenEmail author
  • Hanna Gerlovin
  • Alexandra Femia
  • Jae Cho
  • Suzanne Bertisch
  • Susan Redline
  • Karen J. Sherman
  • Robert Saper
Original Research



Poor sleep is common among adults with chronic low back pain (cLBP), but the influence of cLBP treatments, such as yoga and physical therapy (PT), on sleep quality is under studied.


Evaluate the effectiveness of yoga and PT for improving sleep quality in adults with cLBP.


Secondary analysis of a randomized controlled trial.


Academic safety-net hospital and 7 affiliated community health centers.


A total of 320 adults with cLBP.


Twelve weekly yoga classes, 1-on-1 PT sessions, or an educational book.

Main Measures

Sleep quality was measured using the Pittsburgh Sleep Quality Index (PSQI) global score (0–21) at baseline, 12 weeks, and 52 weeks. Additionally, we also evaluated how the proportion of participants who achieved a clinically meaningful improvement in sleep quality (> 3-point reduction in PSQI) at 12 weeks varied by changes in pain and physical function at 6 weeks.

Key Results

Among participants (mean age = 46.0, 64% female, 82% non-white), nearly all (92%) reported poor sleep quality (PSQI > 5) at baseline. At 12 weeks, modest improvements in sleep quality were observed among the yoga (PSQI mean difference [MD] = − 1.19, 95% confidence interval [CI] − 1.82, − 0.55) and PT (PSQI MD = − 0.91, 95% CI − 1.61, − 0.20) groups. Participants who reported a ≥ 30% improvement in pain or physical function at 6 weeks, compared with those who improved < 10%, were more likely to be a sleep quality responder at 12 weeks (odds ratio [OR] = 3.51, 95% CI 1.73, 7.11 and OR = 2.16, 95% CI 1.18, 3.95, respectively). Results were similar at 52 weeks.


In a sample of adults with cLBP, virtually all with poor sleep quality prior to intervention, modest but statistically significant improvements in sleep quality were observed with both yoga and PT. Irrespective of treatment, clinically important sleep improvements at the end of the intervention were associated with mid-intervention pain and physical function improvements.

Trial Registration Identifier: NCT01343927


back pain chronic pain yoga physical therapy education sleep 



We thank David Felson, MD, MPH, and the Boston University Clinical Epidemiology Research Unit for their constructive review of this paper.

Author Contributions

Drs. Roseen, Gerlovin, and Saper had full access to all of the data in the study and take responsibility for the integrity of the data and the accuracy of the data analysis.

Study concept and design: Roseen, Sherman, Saper.

Acquisition, analysis, or interpretation of data: Roseen, Gerlovin, Femia, Cho, Bertisch, Redline, Sherman, Saper.

Drafting of the manuscript: Roseen.

Critical revision of the manuscript for important intellectual content: Roseen, Gerlovin, Femia, Cho, Bertisch, Redline, Sherman, Saper.

Statistical analysis: Roseen, Gerlovin.

Obtained funding: n/a.

Administrative, technical, or material support: Roseen, Femia, Saper.

Study supervision: Roseen, Saper.

Funding Information

The Back to Health Study (5R01-AT005956) was funded by the National Center for Complementary and Integrative Health (NCCIH). Dr. Roseen is supported by a Ruth L. Kirschstein National Research Service Award (1F32AT009272) from the NCCIH and by the Boston University Clinical and Translational Science Institute (CTSI) Clinical Research Training Program (1UL1TR001430). Drs. Bertisch and Redline are supported in part by NCCIH (R34 AT008923).

Compliance with Ethical Standards

The Boston University Medical Campus Institutional Review Board approved the study prior to data collection. All participants provided written informed consent.

Conflict of Interest

The authors declare that they do not have a conflict of interest.


The funding sources had no role in the design and conduct of the study; collection, management, analysis, and interpretation of the data; preparation, review, or approval of the manuscript; and decision to submit the manuscript for publication. The contents of this manuscript are solely the responsibility of the authors and do not necessarily represent the official views of NCCIH.


  1. 1.
    Kelly GA, Blake C, Power CK, OKeeffe D, Fullen BM. The association between chronic low back pain and sleep: a systematic review. Clin J Pain. 2011;27(2):169–181.PubMedCrossRefGoogle Scholar
  2. 2.
    Alsaadi SM, McAuley JH, Hush JM, Maher CG. Prevalence of sleep disturbance in patients with low back pain. Eur Spine J. 2011;20(5):737–743.PubMedCrossRefGoogle Scholar
  3. 3.
    Tang NK, Wright KJ, Salkovskis PM. Prevalence and correlates of clinical insomnia co-occurring with chronic back pain. J Sleep Res. 2007;16(1):85–95.PubMedCrossRefGoogle Scholar
  4. 4.
    Alsaadi SM, McAuley JH, Hush JM, et al. The bidirectional relationship between pain intensity and sleep disturbance/quality in patients with low back pain. Clin J Pain. 2014;30(9):755–765.PubMedCrossRefGoogle Scholar
  5. 5.
    Finan PH, Goodin BR, Smith MT. The association of sleep and pain: an update and a path forward. J Pain. 2013;14(12):1539–1552.PubMedPubMedCentralCrossRefGoogle Scholar
  6. 6.
    Jones JD, Mogali S, Comer SD. Polydrug abuse: a review of opioid and benzodiazepine combination use. Drug Alcohol Depend. 2012;125(1–2):8–18.PubMedPubMedCentralCrossRefGoogle Scholar
  7. 7.
    Ho KK FP, Pinheiro MB, Silva DA, Miller CB, Grunstein R, Simic. Sleep interventions for osteoarthritis and spinal pain: a systematic review and meta-analysis of randomized controlled trials. Osteoarthritis and Cartilage. 2018.Google Scholar
  8. 8.
    Trauer JM, Qian MY, Doyle JS, Rajaratnam SM, Cunnington D. Cognitive Behavioral Therapy for Chronic Insomnia: A Systematic Review and Meta-analysis. Ann Intern Med. 2015;163(3):191–204.PubMedCrossRefGoogle Scholar
  9. 9.
    Hayden JA, van Tulder MW, Tomlinson G. Systematic review: strategies for using exercise therapy to improve outcomes in chronic low back pain. Ann Intern Med. 2005;142(9):776–785.PubMedCrossRefGoogle Scholar
  10. 10.
    Cramer H, Lauche R, Haller H, Dobos G. A systematic review and meta-analysis of yoga for low back pain. Clin J Pain. 2013;29(5):450–460.PubMedCrossRefPubMedCentralGoogle Scholar
  11. 11.
    Wieland LS, Skoetz N, Pilkington K, Vempati R, D’Adamo CR, Berman BM. Yoga treatment for chronic non-specific low back pain. Cochrane Database Syst Rev. 2017;1:CD010671.Google Scholar
  12. 12.
    Qaseem A, Wilt TJ, McLean RM, Forciea MA, Clinical Guidelines Committee of the American College of P. 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(7):514–530.PubMedCrossRefPubMedCentralGoogle Scholar
  13. 13.
    Irish LA, Kline CE, Gunn HE, Buysse DJ, Hall MH. The role of sleep hygiene in promoting public health: A review of empirical evidence. Sleep Med Rev. 2015;22:23–36.PubMedCrossRefPubMedCentralGoogle Scholar
  14. 14.
    Freburger JK, Carey TS, Holmes GM, et al. Exercise prescription for chronic back or neck pain: who prescribes it? who gets it? What is prescribed? Arthritis Rheum. 2009;61(2):192–200.PubMedPubMedCentralCrossRefGoogle Scholar
  15. 15.
    Yang P-Y, Ho K-H, Chen H-C, Chien M-Y. Exercise training improves sleep quality in middle-aged and older adults with sleep problems: a systematic review. Journal of Physiotherapy. 2012;58(3):157–163.PubMedCrossRefPubMedCentralGoogle Scholar
  16. 16.
    Rogers LQ, Courneya KS, Oster RA, et al. Physical Activity and Sleep Quality in Breast Cancer Survivors: A Randomized Trial. Med Sci Sports Exerc. 2017;49(10):2009–2015.PubMedPubMedCentralCrossRefGoogle Scholar
  17. 17.
    Guthrie KA, Larson JC, Ensrud KE, et al. Effects of Pharmacologic and Nonpharmacologic Interventions on Insomnia Symptoms and Self-reported Sleep Quality in Women With Hot Flashes: A Pooled Analysis of Individual Participant Data From Four MsFLASH Trials. Sleep. 2018;41(1).Google Scholar
  18. 18.
    King AC, Oman RF, Brassington GS, Bliwise DL, Haskell WL. Moderate-intensity exercise and self-rated quality of sleep in older adults. A randomized controlled trial. JAMA. 1997;277(1):32–37.PubMedCrossRefGoogle Scholar
  19. 19.
    Singh NA, Clements KM, Fiatarone MA. A randomized controlled trial of the effect of exercise on sleep. Sleep. 1997;20(2):95–101.PubMedCrossRefGoogle Scholar
  20. 20.
    Vaz Fragoso CA, Miller ME, King AC, et al. Effect of Structured Physical Activity on Sleep-Wake Behaviors in Sedentary Elderly Adults with Mobility Limitations. J Am Geriatr Soc. 2015;63(7):1381–1390.PubMedPubMedCentralCrossRefGoogle Scholar
  21. 21.
    Reid KJ, Baron KG, Lu B, Naylor E, Wolfe L, Zee PC. Aerobic exercise improves self-reported sleep and quality of life in older adults with insomnia. Sleep Med. 2010;11(9):934–940.PubMedPubMedCentralCrossRefGoogle Scholar
  22. 22.
    Eadie J, van de Water AT, Lonsdale C, et al. Physiotherapy for sleep disturbance in people with chronic low back pain: results of a feasibility randomized controlled trial. Arch Phys Med Rehabil. 2013;94(11):2083–2092.PubMedCrossRefPubMedCentralGoogle Scholar
  23. 23.
    Clarke TC, Black LI, Stussman BJ, Barnes PM, Nahin RL. Trends in the use of complementary health approaches among adults: United States, 2002-2012. Natl Health Stat Report. 2015(79):1–16.Google Scholar
  24. 24.
    Fang R, Li X. A regular yoga intervention for staff nurse sleep quality and work stress: a randomised controlled trial. J Clin Nurs. 2015;24(23–24):3374–3379.PubMedCrossRefPubMedCentralGoogle Scholar
  25. 25.
    Cohen L, Warneke C, Fouladi RT, Rodriguez MA, Chaoul-Reich A. Psychological adjustment and sleep quality in a randomized trial of the effects of a Tibetan yoga intervention in patients with lymphoma. Cancer. 2004;100(10):2253–2260.PubMedCrossRefPubMedCentralGoogle Scholar
  26. 26.
    Bower JE, Garet D, Sternlieb B, et al. Yoga for persistent fatigue in breast cancer survivors: a randomized controlled trial. Cancer. 2012;118(15):3766–3775.PubMedCrossRefPubMedCentralGoogle Scholar
  27. 27.
    Mustian KM, Sprod LK, Janelsins M, et al. Multicenter, randomized controlled trial of yoga for sleep quality among cancer survivors. J Clin Oncol. 2013;31(26):3233–3241.PubMedPubMedCentralCrossRefGoogle Scholar
  28. 28.
    Cramer H, Pokhrel B, Fester C, et al. A randomized controlled bicenter trial of yoga for patients with colorectal cancer. Psychooncology. 2016;25(4):412–420.PubMedCrossRefPubMedCentralGoogle Scholar
  29. 29.
    Chen KM, Chen MH, Chao HC, Hung HM, Lin HS, Li CH. Sleep quality, depression state, and health status of older adults after silver yoga exercises: cluster randomized trial. Int J Nurs Stud. 2009;46(2):154–163.PubMedCrossRefPubMedCentralGoogle Scholar
  30. 30.
    Chen KM, Chen MH, Lin MH, Fan JT, Lin HS, Li CH. Effects of yoga on sleep quality and depression in elders in assisted living facilities. J Nurs Res. 2010;18(1):53–61.PubMedCrossRefGoogle Scholar
  31. 31.
    Hariprasad VR, Sivakumar PT, Koparde V, et al. Effects of yoga intervention on sleep and quality-of-life in elderly: A randomized controlled trial. Indian J Psychiatry. 2013;55(Suppl 3):S364–368.PubMedPubMedCentralGoogle Scholar
  32. 32.
    Halpern J, Cohen M, Kennedy G, Reece J, Cahan C, Baharav A. Yoga for improving sleep quality and quality of life for older adults. Altern Ther Health Med. 2014;20(3):37–46.PubMedGoogle Scholar
  33. 33.
    Newton KM, Reed SD, Guthrie KA, et al. Efficacy of yoga for vasomotor symptoms: a randomized controlled trial. Menopause. 2014;21(4):339–346.PubMedPubMedCentralGoogle Scholar
  34. 34.
    Buchanan DT, Landis CA, Hohensee C, et al. Effects of Yoga and Aerobic Exercise on Actigraphic Sleep Parameters in Menopausal Women with Hot Flashes. J Clin Sleep Med. 2017;13(1):11–18.PubMedPubMedCentralCrossRefGoogle Scholar
  35. 35.
    Taibi DM, Vitiello MV. A pilot study of gentle yoga for sleep disturbance in women with osteoarthritis. Sleep Med. 2011;12(5):512–517.PubMedPubMedCentralCrossRefGoogle Scholar
  36. 36.
    Cheung C, Wyman JF, Resnick B, Savik K. Yoga for managing knee osteoarthritis in older women: a pilot randomized controlled trial. BMC Complement Altern Med. 2014;14:160.PubMedPubMedCentralCrossRefGoogle Scholar
  37. 37.
    Kirkwood G, Rampes H, Tuffrey V, Richardson J, Pilkington K. Yoga for anxiety: a systematic review of the research evidence. Br J Sports Med. 2005;39(12):884–891; discussion 891.PubMedPubMedCentralCrossRefGoogle Scholar
  38. 38.
    Saper RB, Sherman KJ, 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;15:67.PubMedPubMedCentralCrossRefGoogle Scholar
  39. 39.
    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(2):85–94.PubMedPubMedCentralCrossRefGoogle Scholar
  40. 40.
    Moore JE LK, Von Korff M, Gonzalez VM, Laurent DD. The Back Pain Helpbook. New York: Perseus Books; 1999.Google Scholar
  41. 41.
    Buysse DJ, Reynolds CF, 3rd, Monk TH, Berman SR, Kupfer DJ. The Pittsburgh Sleep Quality Index: a new instrument for psychiatric practice and research. Psychiatry Res. 1989;28(2):193–213.PubMedCrossRefGoogle Scholar
  42. 42.
    Carpenter JS, Andrykowski MA. Psychometric evaluation of the Pittsburgh Sleep Quality Index. J Psychosom Res. 1998;45(1):5–13.PubMedCrossRefGoogle Scholar
  43. 43.
    Backhaus J, Junghanns K, Broocks A, Riemann D, Hohagen F. Test-retest reliability and validity of the Pittsburgh Sleep Quality Index in primary insomnia. J Psychosom Res. 2002;53(3):737–740.PubMedCrossRefGoogle Scholar
  44. 44.
    Buysse DJ, Germain A, Moul DE, et al. Efficacy of brief behavioral treatment for chronic insomnia in older adults. Arch Intern Med. 2011;171(10):887–895.PubMedPubMedCentralCrossRefGoogle Scholar
  45. 45.
    Cole JC, Motivala SJ, Buysse DJ, Oxman MN, Levin MJ, Irwin MR. Validation of a 3-factor scoring model for the Pittsburgh sleep quality index in older adults. Sleep. 2006;29(1):112–116.PubMedCrossRefGoogle Scholar
  46. 46.
    Hughes JM, Song Y, Fung CH, et al. Measuring Sleep in Vulnerable Older Adults: A Comparison of Subjective and Objective Sleep Measures. Clin Gerontol. 2018;41(2):145–157.PubMedCrossRefGoogle Scholar
  47. 47.
    Patrick DL, Deyo RA, Atlas SJ, Singer DE, Chapin A, Keller RB. Assessing health-related quality of life in patients with sciatica. Spine (Phila Pa 1976). 1995;20(17):1899–1908; discussion 1909.CrossRefGoogle Scholar
  48. 48.
    Ostelo RW, Deyo RA, 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(1):90–94.CrossRefGoogle Scholar
  49. 49.
    Jordan K, Dunn KM, 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(1):45–52.PubMedCrossRefGoogle Scholar
  50. 50.
    Chen X, Wang R, Zee P, et al. Racial/Ethnic Differences in Sleep Disturbances: The Multi-Ethnic Study of Atherosclerosis (MESA). Sleep. 2015;38(6):877–888.PubMedPubMedCentralGoogle Scholar
  51. 51.
    Pearson NJ, Johnson LL, Nahin RL. Insomnia, trouble sleeping, and complementary and alternative medicine: Analysis of the 2002 national health interview survey data. Arch Intern Med. 2006;166(16):1775–1782.PubMedCrossRefPubMedCentralGoogle Scholar
  52. 52.
    Sullivan TR, White IR, Salter AB, Ryan P, Lee KJ. Should multiple imputation be the method of choice for handling missing data in randomized trials? Stat Methods Med Res. 2018;27(9):2610–2626.PubMedCrossRefPubMedCentralGoogle Scholar
  53. 53.
    Kingsbury JH, Buxton OM, Emmons KM. Sleep and its Relationship to Racial and Ethnic Disparities in Cardiovascular Disease. Curr Cardiovasc Risk Rep. 2013;7(5).Google Scholar
  54. 54.
    Hicken MT, Lee H, Ailshire J, Burgard SA, Williams DR. “Every shut eye, ain’t sleep”: The role of racism-related vigilance in racial/ethnic disparities in sleep difficulty. Race Soc Probl. 2013;5(2):100–112.PubMedPubMedCentralCrossRefGoogle Scholar
  55. 55.
    Vitiello MV, McCurry SM, Shortreed SM, et al. Short-term improvement in insomnia symptoms predicts long-term improvements in sleep, pain, and fatigue in older adults with comorbid osteoarthritis and insomnia. Pain. 2014;155(8):1547–1554.PubMedPubMedCentralCrossRefGoogle Scholar
  56. 56.
    Salwen JK, Smith MT, Finan PH. Mid-Treatment Sleep Duration Predicts Clinically Significant Knee Osteoarthritis Pain reduction at 6 months: Effects From a Behavioral Sleep Medicine Clinical Trial. Sleep. 2017;40(2).Google Scholar
  57. 57.
    Chuang LH, Soares MO, Tilbrook H, et al. A pragmatic multicentered randomized controlled trial of yoga for chronic low back pain: economic evaluation. Spine (Phila Pa 1976). 2012;37(18):1593–1601.CrossRefGoogle Scholar
  58. 58.
    Aboagye E, Karlsson ML, Hagberg J, Jensen I. Cost-effectiveness of early interventions for non-specific low back pain: a randomized controlled study investigating medical yoga, exercise therapy and self-care advice. J Rehabil Med. 2015;47(2):167–173.PubMedCrossRefGoogle Scholar
  59. 59.
    Torstensen TA, Ljunggren AE, Meen HD, Odland E, Mowinckel P, Geijerstam S. Efficiency and costs of medical exercise therapy, conventional physiotherapy, and self-exercise in patients with chronic low back pain. A pragmatic, randomized, single-blinded, controlled trial with 1-year follow-up. Spine (Phila Pa 1976). 1998;23(23):2616–2624.CrossRefGoogle Scholar
  60. 60.
    Black DS, OReilly 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(4):494–501.PubMedPubMedCentralCrossRefGoogle Scholar

Copyright information

© Society of General Internal Medicine 2019

Authors and Affiliations

  • Eric J. Roseen
    • 1
    • 2
    Email author
  • Hanna Gerlovin
    • 3
  • Alexandra Femia
    • 1
  • Jae Cho
    • 1
  • Suzanne Bertisch
    • 4
    • 5
  • Susan Redline
    • 4
    • 5
  • Karen J. Sherman
    • 6
    • 7
  • Robert Saper
    • 1
  1. 1.Department of Family Medicine Boston University School of Medicine and Boston Medical CenterBostonUSA
  2. 2.Department of Rehabilitation SciencesMassachusetts General Hospital Institute of Health ProfessionsBostonUSA
  3. 3.Slone Epidemiology CenterBoston University School of MedicineBostonUSA
  4. 4.Division of Sleep and Circadian DisordersBrigham and Women’s HospitalBostonUSA
  5. 5.Division of Sleep MedicineHarvard Medical SchoolBostonUSA
  6. 6.Kaiser Permanente Washington Health Research InstituteSeattleUSA
  7. 7.Department of EpidemiologyUniversity of WashingtonSeattleUSA

Personalised recommendations