An independent expert can point out whether a study is valid and relevant and whether any cautionary notes should accompany its conclusions.
The article provided an accurate, bare-bones description of the study and its main conclusions—that yoga and intensive stretching were similarly effective and were both superior to the self-care intervention.
But it also missed several key points, as detailed in the scoring below. And since the study in the Archives of Internal Medicine was actually accompanied by an independent commentary that could have been cited, these omissions are all the more telling.
So what points might an independent expert have added to the coverage?The most important one is that the subjects in this study were relatively affluent and generally had mild back pain and modest functional limitations. The results of this study may not apply to the large body of patients from less affluent backgrounds with more severe back pain, greater functional impairment, and more complex health problems.
Would a roughneck on an oil rig, an auto mechanic, or a hotel maid gain a similar benefit from yoga or intensive stretching as the subjects in this study? No one really knows.
The availability of these treatments is also an issue. Similarly structured viniyoga programs may not be available in many communities—and it is not clear that most health insurance plans will cover them. The type of intensive stretching program described in this study would appear to be uncommon in the United States. So most patients wouldn’t have access to this intervention.
Lastly, this study did not compare yoga and intensive stretching to “usual care”. So yoga and intensive stretching may be superior to a self-care program, but it is not as clear that they are any better than routine back care as dispensed across the United States.
In the United States, back pain is the ninth most expensive medical condition for women, and the 10th for men, in terms of direct medical costs—with chronic back pain accounting for a disproportionate chunk of those expenses. And the costs of work absence and disability claims related to back pain vastly exceed the medical price tag.
Though Americans spend almost $35 billion per year on the medical treatment of back pain, the prevalence of chronic back pain appears to be rising—and self-rated spinal health among Americans appears be declining. (See Soni, 2011; Freburger et al., 2008; and Martin et al., 2008).
A number of nonsurgical treatments—analgesics, exercise, manual therapies, complementary/alternative therapies, psychological interventions, and multidisciplinary rehabilitation—are modestly effective in the management of chronic back pain. Yet for various reasons, Americans overuse ineffective treatments and underuse effective ones. (See Carey et al., 2009).
So the identification of treatments that facilitate recovery and are popular with patients is a key social and medical priority.
References for This Review:
Balagué F et al., Non-specific low back pain, Lancet, epub ahead of print, October 7, 2011; DOI:10.1016/S0140- 6736(11)60610-7).
Carey TS et al., A long way to go: Practice patterns and evidence in chronic low back pain care, Spine, 2009; 34(7):718–24. Medicine, 2007; 147(7):478– 91.
Freburger J et al., The rising prevalence of chronic low back pain, Archives of Internal Medicine,
Martin BI et al. Expenditures and health status among adults with back and neck problems. JAMA 2008; 299:656-664.
Soni A, Top ten most costly conditions among men and women, 2008, Agency for Healthcare Quality and Research, Statistical Brief #331, 2011. www.meps.ahrq.gov/mepsweb/data_files/publications/st331/stat331.pdf.
The story did not mention the costs or cost-effectiveness of any of the interventions. These are important issues. Individuals who opt for yoga classes, for instance, may have to bear the costs themselves.
The journalist adequately framed and quantified the benefits in terms of both primary and secondary outcome measures.
The article did not discuss adverse events in any of the groups, though the study reported on them. This is an important point, as the New York Times article observed that many people with back pain shy away from exercise programs for fear of exacerbating their symptoms.
The article adequately described the randomized controlled trial and its results. However, it did not adequately describe the limitations of this trial—which looked primarily at subjects with mild-to-moderate uncomplicated chronic back pain. It is not clear that the study conclusions apply to individuals with more severe back pain.
There was no obvious disease mongering in the article. Members of the general public are legitimately concerned about chronic back pain and its consequences.
The New York Times article did not offer commentary from an independent source. The evidence on chronic back pain is complex and challenging, as is the evidence on yoga and stretching. So the article would have benefited from additional expert input. The authors of the clinical trial did not disclose any conflicts-of-interest, so there was no need to report on this criterion in the article.
The New York Times feature did not mention a full range of alternative treatments for chronic back pain. However, it did mention several other potential therapies, including medications, physical therapy, and strengthening exercises.
The writer probably assumed that yoga classes and stretching programs are widely available across the United States. So we’ll award a “satisfactory” here.
But it is not actually all that clear that similar “viniyoga” classes and intensive stretching programs are available in most communities—or that physicians and patients can easily find them. And it is not clear to what extent they are covered by health insurance plans.
The article did not discuss the novelty of the treatment interventions. The intensive stretching class would appear be a novel intervention developed for the clinical trial—and similar programs aren’t widely available around the country. The “viniyoga” program may be less novel, but is distinctive nonetheless.
The article did not rely on a news release. Group Health in Seattle did release a lengthy press release on this study. But the New York Times article did not appear to use it.