“In Class We Were All One.” A Qualitative Exploration of Yoga and Educational Interventions for Predominantly Low-Income and Minority Adults with Chronic Low Back Pain

Abstract

Introduction:

Chronic low back pain (cLBP) can be physically and psychologically debilitating and disproportionally afflicts vulnerable populations. Yoga and education are increasingly common interventions for cLBP yet are understudied in low-income and minority adults. The objective of this qualitative study was to understand the yoga and self-care experience of adults with cLBP from urban, underserved communities who were enrolled in a randomized controlled trial that included these treatments.

Methods:

We interviewed 26 (18 yoga and 8 education) participants. Interviews were transcribed verbatim and analyzed using thematic analysis with codes developed inductively from data.

Results:

Participants from both yoga and education groups reported initial apprehension and ambivalence toward their respective intervention. However, physical and psychological benefits were noted, mainly in the form of improved pain self-management. Communal support and camaraderie reported by the yoga group was absent and desired by education participants. Social factors impeding the ability to sustain yoga practice included transportation, access, and cost, whereas education participants described literacy and language challenges and a general lack of motivation to read the book.

Conclusion:

Yoga and education are viable treatments for adults with cLBP who live in underserved neighborhoods. However, social stigma and socioeconomic barriers may hinder their uptake. Communal support in group-based nonpharmacological treatments is valued and may contribute to participation and clinical outcomes.

ClinicalTrials.gov Identifier:

NCT01343927.

Introduction

Chronic low back pain (cLBP) is one of the most common reasons people seek consultation from their primary care physician and the second most common cause of disability.^1,2 Racial, ethnic, and socioeconomic differences exist in the experience of patients with cLBP and their access and response to treatment.³ Lower socioeconomic status and minority race or ethnicity are associated with greater prevalence and severity of cLBP.^4,5 Treatment guidelines suggest nonpharmacological interventions for patients in pain must address both physical aspects of pain and psychological components to achieve optimal results.⁶ In communities that are under-resourced, elucidating the barriers to nonpharmacological interventions may help increase access and uptake of effective treatment for cLBP. How to best structure yoga and educational interventions for underserved patients with cLBP is unclear as these demographic groups are largely under-represented in previous research.³

The Back to Health Study was a large randomized controlled trial (RCT) that compared the effects of yoga, physical therapy (PT), and education in predominantly low-income and minority participants with cLBP.⁷ We reported 12-week pain and disability outcomes that favored yoga and PT over education, although differences were small and not statistically significant for most comparisons.⁸ Secondary analyses of psychosocial outcomes (e.g., self-efficacy, depression, stress) similarly showed improvements in all three groups but small or no between-group differences.^9

–12 Overlapping treatment characteristics among the three trial interventions may explain the modest differences found between groups.¹³ For example, strategies to address fear avoidance were included in the education and PT groups. The yoga and PT interventions involved a trained professional (yoga instructor or physical therapist) who guided the participant through their rehabilitation. In the yoga and education group, participants learned relaxing breathing techniques.

Elucidating the active components of our yoga, PT, and education interventions, and how they overlap, is important to interpret our findings and to ultimately optimize outcomes of cLBP interventions. Understanding the acceptability of these nonpharmacologic treatments and barriers to access may enhance implementation efforts in underserved communities.

We recently described key elements of PT from qualitative analysis of interviews with the PT participants.¹⁴ Themes included the value of interconnectedness between patients–therapist and building a sense of empowerment through exercise and education. Barriers to PT were minimal—participants were generally receptive to PT, which was considered accessible and affordable under their health insurance. In this report, we additionally analyzed interviews of participants receiving yoga and education interventions. Our trial was the fourth study to compare yoga to an education intervention using The Back Pain Helpbook.^8,15
–17 However, this is the first of these studies to interview participants from each intervention group, which allowed us to compare themes from yoga participants to those in the education group.

Methods

Design

This qualitative study was embedded in the Back to Health Study, a large three-arm RCT of 12-week yoga, PT, and education interventions for cLBP.^7,8 Between June 2012 and November 2013, 320 participants were recruited from low-income and racially diverse neighborhoods of Boston. The Boston University Medical Campus Institutional Review Board approved study procedures.

Participants and interventions

Participants were adults (18–64 years old) with moderate-to-severe cLBP recruited from the Boston Medical Center or one of seven community health centers.

The yoga intervention consisted of 12 weekly 75-minute classes, which included a brief discussion of yoga philosophy, relaxation, and breathing exercises, 55-minute of yoga postures, and a deep relaxation exercise. To encourage home practice, participants were given a study yoga Digital Video Disc, a yoga mat, strap, and block.

The education intervention included The Back Pain Helpbook,¹⁸ a comprehensive self-management book, and a schedule for reading specific chapters over 12 weeks. The book included information on the causes of back pain, guidelines for engaging in daily activities, lifestyle modifications, and tips for managing flare-ups. Additionally, every 3 weeks, participants received a 1–2-page newsletter reiterating main points from the assigned chapters and a 5- to 10-min check-in call from research staff.

Recruitment and data collection

Following the 12-week intervention participants who completed the yoga (n = 125) or education (n = 60) intervention were invited to be interviewed by experienced qualitative interviewers who were not involved in the delivery of either intervention. The semistructured interview guide asked about participants' history of cLBP and their perceptions of, expectation for, and experience with their treatment (Supplementary Appendix A). Open-ended questions such as, “What did you know about yoga before beginning the study?” or “What was your experience with the education book like?” were asked to facilitate discussion directed by those aspects of the treatment participants felt were most relevant. All interviews were conducted in person, lasted 30–60 min, were audiorecorded and transcribed verbatim by research staff.

Demographic and clinical data [pain (Numeric Rating Scale [NRS 0–10])¹⁹; and disability (Modified Roland–Morris Disability Questionnaire [RMDQ 0–23])²⁰] at baseline and follow-up were linked to the participants in the qualitative study. Additional data included treatment expectations (0–10; not at all helpful–extremely helpful) and treatment preference (PT, yoga, or education) before randomization and then treatment satisfaction at 12 weeks (very satisfied, somewhat satisfied, not satisfied or dissatisfied, somewhat dissatisfied, and very dissatisfied).

Analysis

We used an inductive approach to descriptive thematic content evaluation²¹ for transcript analysis. Three authors (C.J., K.C.K., and S.G.) coded transcripts following the recommendations of Braun and Clarke.²² First, each author read all 26 transcripts to familiarize themselves with the data. To develop an initial code list, all three coders simultaneously coded two interviews and developed a coding schema. Next, each coder individually coded the same third interview and then met to discuss and refine the code list. The remaining interviews were coded in blocks of three. Two authors (K.C.K. and S.G.) coded the same three interviews and C.J. coded one of those three. After coding each block, the authors met to reflect upon and revise their code list to ensure agreement among codes. This pattern was followed until all transcripts were coded. Codes were collated into themes.

Themes were broken down, collapsed, or renamed to achieve coherence within each theme and distinction between themes. Themes were then named and defined based on their conceptual meaning and relationship to the original research aim. Finally, a report was written using extracted quotes to tell the story of our participants vividly and accurately. All data were coded and organized using NVivo 12 Plus (QSR International, Doncaster, Australia).

Results

Eighteen of 120 yoga participants and 8 of 60 education participants agreed to be interviewed (Table 1). Of the 26 participants, most were middle aged (range: 37 to 64), female (69%), and black (77%). The majority earned <$40,000/year and were either high school or technical school graduates. Participants in both groups had moderate-to-severe pain (mean NRS = 7.2) and moderate disability (mean RMDQ = 14.8).

Table 1.

Baseline Participant Characteristics, Preferences, Expectation for Treatment, and 12-Week Change in Pain, Disability, and Satisfaction with Treatment

ID	Race	Gender	Age	Income	Education	Preference	Expectation^a	ΔNRS^b	ΔRMDQ^c	Satisfaction^d
Yoga1029	Black	Female	47	$40,000–$50,000	Technical school or some college	PT	5	−2	1	2
Yoga1045	Other	Male	41	$40,000–$50,000	Graduate school	Education	8	−5	−3	2
Yoga1039	Black	Female	50	$20,000–$30,000	Technical school or some college	Yoga	9	−1	−9	1
Yoga1043	Black	Female	37	$10,000–$20,000	High school grad or GED certificate	Yoga	10	−3	−8	2
Yoga1038	White	Male	64	<$10,000	Some high school or less	PT	5	−2	−3	2
Yoga1032	White	Female	48	>$70,000	Graduate school	PT	9	0	0	2
Yoga1046	Black	Male	47	>$70,000	High school grad or GED certificate	PT	7	−2	−9	1
Yoga1035	Black	Male	55	Unanswered	High school grad or GED certificate	Yoga	10	1	−2	1
Yoga1026	Black	Female	52	$30,000–$40,000	Technical school or some college	Yoga	10	−4	−11	1
Yoga1044	Black	Female	54	<$10,000	High school grad or GED certificate	PT	5	0	1	2
Yoga1001	White	Female	47	$30,000–$40,000	Graduate school	PT	9	−2	−12	2
Yoga1040	Black	Female	50	$10,000–$20,000	High school grad or GED certificate	PT	7	−3	−2	1
Yoga1004	Black	Female	40	$10,000–$20,000	High school grad or GED certificate	PT	8	−2	−4	2
Yoga1042	Black	Male	64	$20,000–$30,000	Technical school or some college	Yoga	10	−1	−9	1
Yoga1013	Black	Female	42	Unanswered	Technical school or some college	Yoga	10	−3	−8	1
Yoga1014	Black	Female	45	Unanswered	High school grad or GED certificate	Education	7	−3	−3	1
Yoga1034	Black	Male	54	<$10,000	Unanswered	PT	6	−1	−20	3
Yoga1015	Black	Female	55	$50,000–$70,000	Graduate school	Yoga	9	−4	−12	1
Edu1003	Other	Female	51	$40,000–$50,000	Graduate school	Education	5	1	4	3
Edu1005	Black	Female	62	<$10,000	Some high school or less	None	5	−1	−1	3
Edu1006	Black	Male	49	<$10,000	Technical school or some college	None	9	0	−1	1
Edu1007	Black	Female	50	<$10,000	Technical school or some college	Yoga	0	0	1	5
Edu1008	Black	Female	53	$30,000–$40,000	College graduate	PT	6	−3	−2	−
Edu1011	Black	Female	50	<$10,000	Technical school or some college	Education	5	−2	−5	1
Edu1041	Other	Female	57	<$10,000	Technical school or some college	Yoga	4	−4	−2	1
Edu1010	Black	Male	54	Not reported	High school grad or GED certificate	PT	9	−1	4	3

Expectation for treatment they were randomized to, measured on an 11-point scale, from 0 to 10; higher scores indicate better expectations.

Change in pain, measured on an 11-point NRS; larger negative scores indicate greater improvement; minimal clinically important difference is 2 points.

Change in back-related disability, measured on the 24-point RMDQ; larger negative scores indicate greater improvement; minimal clinically important difference is 3 points.

Satisfaction with treatment was measured on a 5-point scale, from 1 to 5; lower scores indicate greater satisfaction with treatment.

GED, General Education Development; NRS, Numeric Rating Scale; PT, physical therapy; RMDQ, Roland–Morris Disability Questionnaire.

Average expectation of helpfulness for yoga and education treatments was 8.0 (range: 5 to 10) and 5.4 (range: 0 to 9), respectively. Twelve-week pain and disability scores improved, on average, for the yoga group by 2.0 (range: 0 to 5) and 6.3 (range: −1 to 20) points, respectively, and for the education group by 1.3 (range: −1 to 4) and 0.3 (range: −4 to 5) points, respectively.

Compared with the parent trial, our sample was slightly older (mean age = 49.5 vs. 45.3), more female (69% vs. 61%) and were more likely to report being very satisfied with their yoga (50% vs. 43.2%) and education (37.5% vs. 21.3%) interventions. Other baseline and outcome characteristics were similar.

Yoga participants described 4 distinct themes (Table 2): (1) Not for me, (2) Empowerment through body awareness, (3) Communal support and camaraderie, and (4) Inaccessibility. Collectively, these findings told a story of initial apprehension toward yoga, followed by a positive and empowering experience augmented by sense of community and support but restrained by socioeconomic barriers to participation.

Table 2.

Yoga Themes and Exemplar Excerpts

Yoga themes	Participant quotes
Not for me	I think in the beginning I probably did. I probably associated it with…I don't know how to say this…health nuts? (Yoga1026) I felt like I was kind of out of place. The first thing I did was look around and see if there was any men that was there. Cause yoga, I think of it as something for a woman or for a female. (Yoga1046) I don't know, you know, it's just one of those things. The only yoga class that was being held in my area I think was in Milton, and umm, it was a yoga studio and I think it was advertised mostly for women. You know, and what am I gonna do, walk in there, kind of a big guy and be like, “Hey, you know, I've got my sweatpants on, can I try some yoga?” So it was just a little just intimidating to get started with it, to be honest. (Yoga1045)
Empowerment through body awareness	Yoga makes you a lot more aware of your movements and how you need to not move so abruptly. One of the instructors was reminding us how we should get out of our cars with both feet, turning your whole body to get out, and how to get out of your bed. Like I stated earlier, it is a lifestyle. (Yoga1032) So, eventually I started to feel relief in my back and I started to pay more attention to when I went to class and how I felt during class and how I felt after class and then the triggers…and as I'm more aware, then I'm not inclined to do things whether knowingly or unknowingly to cause more harm…so I think that that's definitely where I feel more in control because now I have knowledge. (Yoga1015)
Communal support and camaraderie	With a group treatment you have a lot of other um I would say friends because that's what they become when you're in class that long…friends that can help you, you have fun, and it gives you that momentum to want to keep going. (Yoga1043) I didn't feel any sense of sort of embarrassment or being uncomfortable for being there because everybody's in the same boat, you know we're all working toward the same goal. (Yoga1045) It's like a connection. So many people. When you got back pain, you got back pain. You say, “ooh I can't do that because of my back.” But then you get in the class and there are 6 or 7 other people that got back pain. And I thought I was doing more than them or they were doing more than me. You know, everybody wasn't the same in that class. We were working at it. (Yoga1034)
Inaccessibility	It's just a little challenging for me sometimes because I'm a single father and my class being on a Saturday, there's certain things I have to work around. (Yoga1046) Yeah, like motivated, too, though, cause I have to catch a bus, then I have to catch the train. So I'm commuting two ways just to get there within the hour. (Yoga1035) A: It was easy for me even though I had to take public transportation. It was fairly easy. Q: Did you not live near one of the sites? A: No. Q: That wasn't a problem getting to class? A: No… I had to take several busses and whatnot to get there but it was ok.

Our education themes were (Table 3): (1) Credibility of a self-care book, (2) Empowerment through knowledge, and (3) Disengagement. These participants were largely skeptical of an educational intervention for their back pain, but then reported learning techniques to manage their pain while reporting barriers to engagement in their treatment.

Table 3.

Education Themes and Exemplar Excerpts

Education themes	Participant quotes
Credibility of a self-care book	No, I actually thought, before I started reading it, there's no way a book can tell me how I feel or how to prevent how I feel. This is not like some psychosomatic, all-in-my-head type pain. (Edu1003) When I first got the book, I said damn, I gotta read? I'm serious, I said, how is this gonna help me by reading? But then as you read along, they start telling you little pieces by pieces what to do so you get the hang of it. But first when they gave me a book I said damn, I'm serious, what is the book gonna do for me? (Edu1011)
Empowerment through knowledge	It's like, you know what, wait a minute, If I do this stretch slowly this will ease up the tensions in this side of me and then I can do it this way - you know, little things that I didn't pay attention to before…In a sense, yes, I have more control over it. It's not dictating what I can and can't do anymore. Yes, I still have to be cautious in a lot of things I do but I'm not limited in the things I can do anymore. (Edu1003) I know I can function, maybe not fully, but I can function like anybody else can. It might be a little slower, it might be not up to the point I want it to be, but I still can do it. (Edu1005) Well I plan to be more active, I plan to go on with my life, just because—I know maybe the back pain will always be there, but if I want any kind of future, any kind of life, I got to try a little harder to do what I got to do. (Edu1005)
Readability and social isolation	It was just boring to begin with ‘cause I wasn't into…I'm used to reading, but not books like that, so like I had to put one book down to start this one. (Edu1011) And the book should be a lot simpler so people can really understand it and get something out of it. The way it is now right, you almost have to be a high school graduate, you know what I mean, to really get through it from page to page and find out what you have to do and where you're at and where you need to be with this book. (Edu1010) It's something on my mind that I would like to talk with people about how they are getting through their back issues. I would love to do that. That should be a component in your study…I can take a little more value from this session if this conference room was with people who read the book, and they mention experiences, which would help me if I heard them as well. What they did before and after. What they are finding helpful that they learned in the book. (Edu1006) People like contact and people like to know that there's someone else out there that's in the same situation. So, that being said, like I said if you have like a little group, five ten or whatever, and someone's showing you the exercises. (Edu1007)

Themes from the yoga group

Not for me

Our yoga participants described their perceived stereotype of gender and body type of people who do yoga, which they did not align with their background. For example: “I heard of yoga. You know, just being from the ghetto. Only females take yoga” (Yoga1034), and “Just like, you know, you're tiny, you don't eat meat. So that's what I associated it with” (Yoga1044). Male participants, in particular, expressed preconceived stereotypes toward other males who do yoga: “Yeah, just like the gay guys. If you take yoga and you are a guy, you are gay” (Yoga1034).

Empowerment through body awareness

Being more aware of their body helped patients take more control of their pain. For example, one participant said, “Cause when my mind is full of other stuff, I really don't know what's going on. But if you get relaxed you listen to your body much better and you feel every part of your body” (Yoga1001). Asked how this helped with their pain, another participant replied, “When you are able to focus on exactly where the pain is, you can work on that” (Yoga1013).

Communal support and camaraderie

Participants spoke frequently about the positive environment created by the instructors and the other participants in the study, which alleviated initial apprehension: “At first, I was a little nervous when I went in there…I didn't know I was going to be working that close with so many people. But [the instructor] made me feel so comfortable and they were really nice” (Yoga1044). Notably, practicing yoga with other participants who had cLBP created a sense of community:

“In class we were all one. We looked out for each other and when someone wasn't there, we'd ask about them.” (Yoga1026)

“It helped that we could share our experiences…which made me appreciate that there are people with more pain than me. I think all being in the same boat we understood each other and could learn from one another.” (Yoga1032)

Inaccessibility

Barriers were namely distance/transportation and cost, which were related in some cases. Said one participant: “…the distance from where I live to get over to there is just, you know, I have to catch like two to three buses to and that's not fun when my finances doesn't allow me right now” (Yoga1040). Yoga classes in the study were free, however, participants acknowledged they would have to find discounted classes to be able to continue practicing after the study: “Oh yeah. I'm not sure how am I going to do that. I cannot spend so much money, so that's one thing, I found a deal that 5 yoga class is for 20 dollars something” (Yoga1001).

Themes from the education group

Credibility of self-care

Many participants doubted that education would have any positive impact on their back pain. For example, “No, I actually thought, before I started reading it, there's no way a book can tell me how I feel or how to prevent how I feel. This is not like some psychosomatic, all-in-my-head-type pain” (Edu1003). There was a predominant belief that simply reading could not help with a physical feeling of pain. Participants noted that they would have preferred the yoga or PT group because those interventions were physical: “Again, I didn't want to be assigned to the education group because I thought it would be just information, like pamphlet type of try this and that. I wanted to get something physical that was hands-on that someone could show me and tell me” (Edu1006).

Empowerment through knowledge of self-care strategies

Participants reported learning more about their pain and gaining tools to deal with it. One participant stated “…being able to apply the tips and information as designed consistently. I would go back and read some of it and try to apply like I was doing it wrong and get better results” (Edu1006). Another participant found that simple strategies such as periodic “movement breaks” made her desk job less painful. Equipped with such strategies was liberating: “Because then that's 5–6 years that I was in excruciating pain almost daily and my life was limited to this little box. And now I can venture off with caution but with knowledge on how to get me through the pain” (Edu1003).

Disengagement

Participants reported difficulty engaging with the book for various reasons. For some participants, they struggled interpreting what the book was saying: “Well, it wasn't easy because a lot of the words and things I didn't really understand, and to understand something fully you gotta go back and read over it” (Edu1005). For other participants, the lack of comprehension was due to a language barrier: “You know, the first time when I go, I feel sad. Because when I saw they gave me the book I come in very, very sad. And I say, this is English? I don't understand too much English for read. And it's very hard” (Edu1008). Some participants felt that the book did not hold their attention and suggested a group-based approach to enhance the experience:

“It was challenging, um, yeah it was challenging. I just wouldn't do it, it just wasn't something that I wanted to do and I just couldn't do it. Not cause I physically couldn't do it, I just couldn't bring myself to do it.” (Edu1007)

“It's something on my mind that I would like to talk with people about how they are getting through their back issues. I would love to do that. I can take a little more value from this session if this conference room was with people who read the book, and they mention experiences, which would help. What they are finding helpful that they learned in the book.” (Edu1006)

Discussion

Main findings

Our qualitative study sought to better understand the experiences of 26 adults who received either yoga or education interventions for cLBP. In the yoga group, themes involved a belief that yoga was not for them, empowerment through body awareness, a sense of communal support, and inaccessibility to practicing outside the study. In the education group, there was a similar theme of empowerment, although through knowledge. Additionally, our education participants spoke of preconceived doubts toward the value of education over more physical or hands-on therapies, and expressed barriers to the book that may have been overcome had there been a communal aspect.

Essential treatment characteristics

Participants from both groups described a newfound sense of confidence in managing their cLBP. In the yoga group, participants became aware of postures and activities that were potentially harmful or painful, and felt more control knowing how to avoid or manage pain flare-ups. Likewise, our education participants gained a better understanding of pain and provided coping skills.^23,24 A similar theme of empowerment was found in our PT data.^12,14 PT participants described increased self-efficacy achieved through practicing painful movements, motivation from physical therapists and other patients, and control of physiological arousal (e.g., breathing to decrease anxious feelings). Collectively, findings from these two studies suggest that an intervention that combines pain education, exercises specific to painful movements or activities, and techniques such as focused breathing and body awareness, may positively affect self-efficacy in patients in pain.

The communal aspect of yoga and PT groups was lacking in our education participants. Our yoga participants developed friendships with their instructors and classmates, and our PT participants spoke of bonding with their therapist and connecting other PT patients. Multiple education participants expressed a desire to have a “book club,” facilitated by an instructor with other cLBP patients to discuss what they were learning and how they were using the book. In addition, both yoga and PT participants found value in the individualized attention they received from their instructor or therapist. There is likely a balance between individualized care and communal support that can optimize treatment outcomes. Conceivably, integrating elements of a group (e.g., communal support, social camaraderie) would augment an individualized exercise-based educational intervention such as the recently published GLA:D^® Back program.²⁵

Barriers to treatment

Primary concerns for our yoga participants were acceptability, cost, and access. Consistent with previous reports,^26,27 our yoga participants' initial impressions were that yoga was not for them, citing stereotypes of fit or affluent white women. Despite this, our quantitative data suggested most yoga participants expected that it would be helpful. Thus, a dichotomy existed between appropriateness and perceived effectiveness of yoga. Environmental barriers were predominantly access, transportation, and, after the study concluded, cost of yoga class. Implementation of yoga in low-income settings may innovative financial strategies such as covering yoga sessions for cLBP, funding yoga studios in underserved communities, or offering “pay what you can” classes.²⁸ By contrast, barriers for education group largely revolved around the perceived value and readability of the book.

Almost all education participants had low expectations for the book, and some felt bored by the content, while others struggled with literacy and language challenges. Therefore, strategies to promote yoga and carefully selected educational materials to lower-income and racial/ethnic minority populations would need to first address gaps in knowledge or held beliefs (stigma, patient expectations) that may limit adoption in usual care.²⁹ Current efforts include integrating cultural music into yoga classes and establishing black yoga organizations.³⁰

Limitations

Our study has several important limitations. First, response rate was low, yielding only 14% of potential participants. Second, response bias is likely in our yoga group as nearly all participants experienced an improvement in pain and disability. Thus, we may not have a representative subsample of a yoga group. The participant demographics in our sample do reflect the broader study population, however, due to low response and favorable outcomes, we cannot be certain that saturation of our themes was met. Last, inclusion to the parent study did not mandate a certain level of English reading comprehension. Therefore, literacy challenges expressed by our participants were partly a factor of an incompatible educational intervention.

Conclusions

Yoga and education are increasingly common interventions for cLBP. Combining essential elements of yoga and education, such as body awareness, communal support, and instructor-led group exercise and education, may enhance treatment. However, accessibility, cost, and social stigma of yoga, as well as literacy and motivational challenges of an educational book, pose significant barriers to acceptability and adoption in low-income and minority populations.

Footnotes

Authors' Contributions

All authors have reviewed and approved the article and agree with submission to the Journal of Integrative and Complementary Medicine. C.J., K.C.K., S.G., E.J.R., and R.B.S. had full access to all 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: C.J. and R.B.S. Acquisition, analysis, or interpretation of data: C.J., K.C.K., S.G., E.J.R., and R.B.S. Drafting of the article: C.J., K.C.K., S.G., and E.J.R. Critical revision of the article for important intellectual content: C.J., K.C.K., S.G., E.J.R., R.B.S., and K.J.S. Analysis: C.J., K.C.K., and S.G. Study supervision: R.B.S.

Author Disclosure Statement

All authors declare no conflicts of interest, financial or otherwise.

Funding Information

The Back to Health Study (5R01-AT005956) was funded by the National Center for Complementary and Integrative Health (NCCIH). Dr. Roseen also received support from NCCIH (K23AT010487-01).

Supplementary Material

Supplementary Appendix A

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