# Exercise as it relates to Disease/Pilates and Yoga group exercises to relieve neck pain
## What is the background of this research?

With an ageing population in Australia, chronic neck pain (CNP) and associated back pain is becoming more prevalent, with 70-80% common for back pain, and 30-40% for neck pain in the Australian population in the last 10 years (1). CNP and back pain have several limitations, as its restricting nature reduces one’s quality of life. In recent years, more patients who suffer from chronic neck and back pain are pursuing methods to combat neck and back pain (2). Complimentary methods, such as yoga and Pilates are used in the health industry for not only a form of exercise, but also for physiotherapy treatment, post rehabilitation transition and community wellness (3). Functional Pilates and yoga combine physical and mental focus to increase relaxation and muscle strength, especially core stability (4). This is achieved through breathing control and complex movement sequences. The purpose of Dunleavy’s and his cohorts’ study is to “determine the effectiveness of Pilates and yoga group exercise interventions for individuals with chronic neck pain (CNP) (3).

## Where is this research from?

This research was conducted in 2015 by K. Dunleavy, K. Kava, A. Goldburg, M.H. Malek, S.A. Talley, V. Tutag-Lehr, and J. Hildreth. These physiologist specialists are based within health-related faculties across Wayne State University, University of Florida, and University of Michigan-Flint. This study was conducted across these four locations, however, was approved by Wayne State University. Upon approval of the completion of the research, the article was published by Elservier Ltd for the Chartered Society of Physiotherapy, which is a governing body that aim to provide adequate and high quality rehabilitation services and protect the quality of physical treatment.

## What kind of research was this?

To effectively gather the appropriate information, the authors used a quasi-randomised parallel controlled design, which is also known as a Randomised Controlled Trial (RCT). This is where participants are randomly and alternately categorised into groups within a controlled setting. This type of study reduces any bias that may occur during the research. RCT balances out the different attributes between participants in each group, reducing bias and provides results that can be analysed in a cause-effect relationship between an intervention and an outcome (5). It is notable that that quasi-randomised study used highlights the effectiveness that the interventions have on an individual, as well as the safety measures put into place (5).

## What did the research involve?

Participants were first pre-screened to identify any previous underlying health or medical issues that may prevent restrictions when performing physical activity. These participants were recruited from various settings, physiotherapy clinics, fitness and community settings and email lists. They were then assigned either yoga, Pilates or control based on random convenience. An individual baseline measure for each participant was recorded prior to set the standard for everyone. The study was conducted over 18 weeks, with data collection being recorded after six weeks and 12 weeks. The data being collected includes:
* Neck Disability Index (NDI) = This is a 10-question scale (0-5) which indicates the difficulty of daily activities and quality of life living due neck soreness, often used within a clinical setting.
* Pain ratings = This 11-point numeric rating scale (NRS) helps indicate the level of soreness or pain. The questionnaire includes questions concerning overall pain, pain including daily life activities and soreness when performing overhead activities.
* Range of Movement (ROM) = ROM and Cervical ROM is tested for adequate movement in all directions. A score is calculated by the sum of all movements in a direction, the by finding the mean of three trials. Dunleavy and Goldberg commend Cervical ROM as a moderate-to-excellent inter-rater reliability (2013).
* Posture = Measurements were taken with a clinical setting by the participants in a neutral sitting position, with both feet on the floor and hips at a 70-degree angle. Posture measurements work in conjunction with Cervical ROM.
* Exercise intervention = yoga and Pilates classes were instructed by qualified rehabilitation trainers in conjunction with physiotherapists with adaptive yoga training.
These data points are then classified into four categories; NDI, average pain, upper-extremity pain, and sustained-activity pain. All participants involved attended a 12-week intervention consisting of 1-hour sessions. Each class could be individually modified to suit each participants fitness level. Over the 12 weeks, with yoga and Pilates, instructors are educating participants about positioning, body mechanism and movement strategies, as well as mental focusing, breathing control and spinal alignment. Yoga classes specifically focused on specific postures, relaxation, and meditation, whereas the Pilates group focused on core stabilisation and spinal alignment (3). In addition to measuring pain, measuring improvements on muscle and core strength would also help create a deeper understanding on how CNP and back pain can be reduced. For example, Ulug conducted a research concerning CNP, where they compared measurements of the neck muscles and how they improved over a course of time (4).

## What were the basic results?

Overall, the results show that yoga and Pilates can decrease neck and lower back pain, as well as stiffness, tension, and disability of the spine within a moderate-to-large effect size (yoga = 1.0-1.8, Pilates = 0.7-1.0). This range was concluded that the short-term follow up. The effect size can be classified as the “magnitude of the differences between interventions and control groups” (2). The primary outcome for this study was assessing the NDI to fully understand the impact yoga and Pilates have on this region. The average NDI score improved across all classes, suggesting that relaxation and stretching techniques that are apparent in yoga and Pilates classes play a role in extinguishing neck pain. Adding to this, Uluğ and Yılmaz conducted a similar study that suggests that chronic neck and back pain sufferers opt to alternative methods of pain relief (4). No further improvements were found in the control group.
Week 12 mean Difference from Baseline :
| Parameter | Pilates (n=20) | Yoga (n=19) | Control (n=17) | P-value |
| NDI | -4.3 (-6.9 to -1.6) | -4.7 (-7.4 to -2.1) | -0.3 (-2.5 to 3.1) | P < 0.05 |
| Average Pain | -0.9 (-1.5 to -0.3) | -0.3 (-0.9 to 0.4) | -0.2 (-0.4 to 0.86) | P <0.05 |
| Upper Extremity Pain | −1.7 (-2.6 to -0.8) | -1.1 (-2.2 to -0.1) | −0.3 (−1.4 to 0.8) | P = 0.0057 |
| Sustain-Activity Pain | -1.7 (-2.4 to -0.9) | -1.6 (-2.4 to -0.8) | −0.2 (−1.1 to 0.7) | P <0.05 |
| ROM and Posture | No group × time interaction for range of movement or posture variables | P =>0.05 |
Dunleavy and his team chose parameters that increases the validity and reliability of this study. For example, the average pain appropriately measures the overall pain experienced. As chronic neck and back pain is more prevalent in older working adults, therefore measuring and evaluating comfort and stiffness in everyday activities is beneficial to this study as it provides a wider range of knowledge about this area. To improve this study, further studies concerning soreness and level of discomfort during and after exercise can broaden the research area, increasing validity and depth of research.

## What conclusions can we take from this research?

In conclusion, it is possible to heal majority of chronic neck and back pain through sufficient and consistent Pilates and yoga exercise, decreasing stiffness and joint pain in these areas. There were significant improvements across all outcomes in both yoga and Pilates exercise groups, compared to the control group. The study design that was implemented helped the researchers conclude that both yoga and Pilates is a safe way of exercising to decrease other health-related risks along with neck and back pain. The study results will vary between each participant as everyone will experience different extremities of chronic neck and back pain and will participate in these interventions differently. In addition to this, yoga and Pilates are more commonly practiced my females, therefore this study is primarily based around females.

## Practical advice

Brämberg et al. explain that to reduce neck and back pain sufficiently using these techniques, you should adopt these interventions in your routine two/three times per week, allowing time to fully recover between each session (1). If participating in yoga or Pilates to help relieve chronic neck and back pain, it is important to be consistent with this practice to see long-term results. In addition to this, a follow-up is advised to ensure that long-term effects of the chosen intervention are beneficial, in conjunction with a health professional such as a physiotherapist, yoga/Pilates instructor or exercise physiologist (6).

## Further information/resources

Chronic Neck and Back Pain
Effects of Yoga and Pilates on an Individual
Yoga and Pilates associated with Lower back Pain

## References

* Brämberg E, Bergström G, Jensen I, Hagberg J, Kwak L. Effects of yoga, strength training and advice on back pain: a randomized controlled trial. BMC Musculoskeletal Disorders. 2017;18(1).1.
* Furlan A, Yazdi F, Tsertsvadze A, Gross A, Van Tulder M, Santaguida L et al. A Systematic Review and Meta-Analysis of Efficacy, Cost-Effectiveness, and Safety of Selected Complementary and Alternative Medicine for Neck and Low-Back Pain. Evidence-Based Complementary and Alternative Medicine. 2012;2012:1-61.
* Dunleavy K, Kava K, Goldberg A, Malek M, Talley S, Tutag-Lehr V et al. Comparative effectiveness of Pilates and yoga group exercise interventions for chronic mechanical neck pain: quasi-randomised parallel controlled study. Physiotherapy. 2016;102(3):236-242.
* Uluğ N, Yılmaz �, Kara M, Özçakar L. Effects of Pilates and yoga in patients with chronic neck pain: A sonographic study. Journal of Rehabilitation Medicine. 2018;50(1):80-85.
* Hariton E Locascio J. Randomised controlled trials - the gold standard for effectiveness research. BJOG: An International Journal of Obstetrics & Gynaecology. 2018;125(13):1716-1716.
* Sorosky, S., Stilp, S., & Akuthota, V. (2008). Yoga and pilates in the management of low back pain. Current Reviews in Musculoskeletal Medicine, 1(1), 39–47.https://doi.org/10.1007/s12178-007-9004-1