Yoga,Physical Therapy and Home Exercise Effects on Chronic Low Back Pain: Pain Perception,Function,Stress,and Quality of Life in a Randomized Trial

Abstract

Low back pain is a common health problem. In this study, we investigated the effects of yoga, physical therapy (PT), and home exercise (HE) on pain perception, function, stress, and quality of life in chronic low back pain (cLBP). We randomly assigned 54 participants to three distinct treatment groups: (a) a physical therapy group (PT) who received spinal stabilization exercises (SSE) combined with local heat and transcutaneous electrical stimulation; (b) a home exercise group (HE) who received SSE as part of the home program; and (c) a yoga group who received yoga exercises. The primary outcome measures were a Visual Analog Scale (VAS) for measuring pain, and the Oswestry Disability Index (ODI) to measure function. Secondary outcome measures were the Tampa Kinesiophobia Scale (TKS), Central Sensitization Inventory (CSI), pain sensitivity (L3 and deltoid R/L PPTs), Spielberger State-Trait Anxiety Inventory (STAI), plasma cortisol and DHEA-S levels, Transversus Abdominis (TrA) muscle activation, and the Nottingham Health Profile (NHP). Assessments were conducted before and after a six-week intervention period. All three groups demonstrated improvements in pain on the VAS, function on the ODI, pain sensitivity on the L3 and deltoid R/L PPTs, CSI, anxiety on the STAI, TrA muscle activation, and quality of life on the NHP (p < .05). The PT group exhibited a more pronounced improvement on the ODI score (p < .05) than the other groups. Cortisol levels only decreased in the PT group (p < .05). The exercises did not impact DHEA-S and NHP-S parameters. Thus, all interventions resulted in decreased stress, pain intensity, pain sensitivity, central sensitization, and improved function and quality of life; there was no singularly superior approach between interventions. These findings will aid in tailoring treatment programs for managing cLBP according to individual needs.

Keywords

physiotherapy low back pain exercise yoga stress

Introduction

Low back pain (LBP) has emerged as a global health concern, as it impacts individuals of all age groups. It is a multidimensional public health problem that negatively affects individuals and families, and it is a financial burden to the economies of all societies (Buchbinder et al., 2013). When LBP endures for three months or more, it transitions into the realm of “chronic LBP (cLBP)” (Meucci et al., 2015). In the context of cLBP, there is substantial evidence that it results in modifications within the somatosensory system, manifesting as pain hypersensitivity and hyperalgesia, indicative of peripheral and central sensitization processes (Starkweather et al., 2016). Additionally, some past research has shown that psychosocial and emotional factors are strong predictors of cLBP (Bener et al., 2013; Picavet et al., 2002).

The complex nature of cLBP, including behavioral, psychological, and social factors, makes its management challenging. Innovations in treating LBP over the last three decades have led to changes in the primary recommendations of clinical guidelines. There is now a greater emphasis on self-management, physical and psychological therapies, and some forms of complementary medicine, with less emphasis on pharmacological and surgical treatments (Balagué et al., 2012; Foster et al., 2018). Ongoing concerns about the risk/benefit ratio of pharmacologic agents and inadequate results in clinical trials, the vast geographical and practitioner variability of surgical procedures, the similar or only modestly greater efficacy of surgical compared to nonsurgical approaches, and the lack of difference in the long term, the cost, and the higher risk of adverse events all suggest that conservative approaches should be the first-line treatment approach. In the absence of a response to conservative treatment, pharmacologic and surgical treatment should be considered for appropriate individuals (Buchbinder et al., 2018; Foster et al., 2018).

Physical therapy and rehabilitation is an essential part of the conservative approaches used in treating LBP (Foster et al., 2018). Exercise is a proven method for treating cLBP among specific physical therapy approaches. Various exercise interventions are used for cLBP, including stretching, strength, pilates, aerobics, mind-body, and core-based exercises (Fernández-Rodríguez et al., 2022). Exercises prescribed by therapists can be practiced in different settings, including clinics, gyms, and at home. Regardless of the application location, exercise training improves pain intensity and functional limitations in individuals with cLBP (Quentin et al., 2021). In recent times, pain has been viewed from a biopsychosocial perspective, and exercise approaches that support the individual both physically and psychosocially are preferred (Flor & Hermann, 2004). Yoga and spinal stabilization exercises (SSE) are commonly used conservative treatments for this purpose. Yoga, an ancient Indian practice, includes breathing, asana (yoga posture), and relaxation exercises. It is intended to improve body posture and emotional and physical well-being and reduce anxiety and pain (Zhu et al., 2020). SSE principles include retraining core muscles, such as the transversus abdominis and lumbar multifidus, for neutral spine stability. Improvement of lumbopelvic motor control and stability provides postural awareness and reduces pain and disability (Frizziero et al., 2021).

Despite the multitude of treatment and healthcare resources available for LBP, the prevalence and disability rate for LBP remains high, and there is no consensus on ‘best practice.’ Exercise is ubiquitously recommended in practice guidelines (Corp et al., 2021; Foster et al., 2018), but effect sizes for pain and disability outcomes are small to moderate, and direct comparisons of exercise interventions have often failed to demonstrate the superiority of one intervention over another (Gilliam et al., 2023; Hayden et al., 2021). Approaches in the treatment of LBP have mainly focused on pain and disability. However, pain is different from nociception; it is multidimensional, involving not only A-delta fiber and C fiber activation, but also contextual emotional, cognitive, and behavioral elements (Flor & Hermann, 2004). Assessment of this aspect of pain has taken a back seat in this research. For these reasons, there is a need to compare the effectiveness of different conservative approaches to these aspects of pain to determine an optimal LBP treatment approach.

Our primary aim, in this study, was to compare the effects of physical therapy, yoga, and home exercises on pain intensity and pain-related disability. Our secondary objective was to assess the impacts of physical therapy, yoga, and home exercises on pain-related fear, anxiety, pain sensitivity, central sensitization, and quality of life (QoL).

Accordingly, we tested the following hypotheses:

• Hypothesis 1 (H1): Yoga, physical therapy, and home exercises will have different effects on pain intensity and pain-related disability.

• Hypothesis 2 (H2): Yoga, physical therapy, and home exercises will have different effects on pain-related fear, anxiety, pain sensitivity, central sensitivity, and quality of life (QoL).

Method

Study Design and Ethical Considerations

We conducted this study with a randomized parallel 3-arm-active control trial at Hacettepe University, Faculty of Physical Therapy and Rehabilitation, Spine Health Unit. Our University Ethics Committee (GO 15/81) approved the study’s protocol. The study was carried out following the Helsinki Declaration, and all participants signed an informed consent document before the investigation. The clinical trial number of the study was NCT03676062.

Participants

We recruited individuals with physician-diagnosed non-specific cLBP. Participant eligibility criteria were to be aged between 25 and 55 years (Akbarnia et al., 2016; Elders et al., 1991) and to have experienced ongoing pain for at least three months. Individuals were excluded if they reported any previous extensive spinal surgery (greater than single-level fusion or discectomy) or any spinal surgery within the past six months, were diagnosed with serious spinal pathology (cancer, inflammatory arthropathy, or acute vertebral fracture), had been diagnosed with a neurological disease, or were currently pregnant, or had attended or were attending exercises classes, yoga or were otherwise being treated for LBP.

Interventions

Physical Therapy Program (PT)

The physical therapy (PT) group underwent a PT treatment program that included 20 minutes of Hotpack, conventional Transcutaneous Electrical Nerve Stimulation (TENS), and spinal stabilization exercises (SSE). This program was implemented for six weeks, at a pace of three 60-min sessions per week. SSE within this program was developed according to the three phases of motor learning, considering the individual’s motor learning ability (Hodges, 2003). The first phase included teaching participants the importance of core muscles (diaphragm, transversus abdominis, multifidus, pelvic floor) in spine stability and how to activate these muscles correctly and gain neutral spine position awareness. After demonstrating the ability to activate these muscles, both in isolation and simultaneously, participants moved on to the second phase in which upper and lower limb movements were accompanied by core muscles co-activation while maintaining neutral spine posture in different body positions (supine, prone, bridging, quadruped, side-lying, sitting, and standing). In the third phase, core muscles co-activation was performed while standing on a balance board, sitting on a gym ball, and during functional tasks (see Figure 1).

Figure 1.

Examples of SSE According to Phases of Motor Learning.

Home Exercise Program (HE)

We gave only SSE to individuals in the HE group. Individuals in this group received SSE as a home program. We instructed them to perform these exercises three days/week for six weeks. We called them once a week, checked their exercises, and monitored their exercise progression. The exercises’ content in the program progressed in the same direction as the PT group, following the three phases of motor learning. To encourage exercise adherence, we gave participants a booklet containing information about LBP, daily life recommendations, and prescribed exercises.

Yoga Program

For participants in the Yoga group, we conducted a six-week Hatha Yoga program in group settings of 6–8 individuals at a pace of three sessions per week, with each session lasting 60 minutes. The Yoga sessions were facilitated by a certified yoga instructor with eight years of instructional expertise who also held qualifications as a physical therapist. All sessions were conducted uniformly under standardized conditions encompassing consistent room settings, lighting, and ambient temperature. The yoga program encompassed a comprehensive array of activities, including breathing exercises, warm-up routines, a series of yoga postures (asanas), and relaxation techniques. The detailed program content is given in Table 1. The yoga postures (asanas) were selected by an experienced physiotherapist well-versed in spinal health. The yoga program was performed in a gentle style, and yoga postures were adapted to the capabilities of each individual to prevent injury. Over the course of the six-week duration, the complexity of the postures was progressively heightened, advancing from simpler to more intricate positions. Comprehensive information pertaining to the specific asanas can be found in Table 2.

Table 1.

Content of Yoga Sessions.

Curriculum (sessions) elements	Time (min)
Breathing exercises	10
Instant relaxation tecniques (IRT)	2-3
Warm ups	10
Quick relaxation tecniques (QRT)	3-5
Sun salutation (suryanamaskar)	10
Yoga postures (asanas)	20
Deep relaxation tecniques (DRT)	10-15
Total time	≅60 minutes

Table 2.

Yoga Postures (Asanas) in the Yoga Sessions.

Yoga Postures (Asanas)	Week 1	Week 2	Week 3	Week 4	Week 5	Week 6
Ardha Kati Çakrasana	X	X	X	X
Ardha Çakrasana	X	X	X	X
Padahastasana	X	X	X	X
Vrikşasana	X	X	X	X	X	X
Natarajasana					X	X
Vrabhadrasana I	X	X	X	X
Vrabhadrasana II		X	X	X
Parşva Konasana					X
Parivritta Parşvakonasana						X
Parivritta Trikonasana			X	X
Vakrasana	X	X	X	X
Ardha Matsyendrasana				X	X	X
Matsyendrasana					X	X
Gomukasana					X	X
Uştrasana					X	X
Şaşankasana					X	X
Supta Udarakarshanasana	X	X
Shavaudarakarshanasana			X	X
Setubandasana			X	X
Navasana					X	X
Pavanamuktasana					X	X
Tiryaka Bujangasana					X
Bujangasana						X
Ardha Şalabasana					X
Şalabasana						X
Sarpasana						X

Note. *Each asana was held for approximately five breaths.

Outcome Measurements

We recorded participants’ socio-demographic data before treatment and evaluated these data at baseline and after the six-week treatment interventions, with outcome measures detailed below.

Primary Outcome Measures

Pain Intensity

We used the Visual Analog Scale (VAS) to evaluate the participant’s low back pain intensity during resting and activity (Shafshak & Elnemr, 2021). The VAS is a self-report scale consisting of a horizontal line (10 cm long) with anchor points of “no pain” and “unbearable pain.” The participants were asked to mark the line that best described their pain intensity.

Pain Related Disability

We evaluated the participants’ pain-related disability with the Oswestry Disability Index (ODI) developed by Fairbank and Pynsent (Fairbank & Pynsent, 2000). This questionnaire has been validated in Turkish (Yakut et al., 2004) (with an internal consistency coefficient of 0.938). It has ten items with six possible answers, each scored from 0–5 points. This scale contained questions about functional activities, personal care, lifting, walking, sitting, standing, sleeping, social life, and traveling. The total score of the instrument is obtained by summing the scores on the ten items, with total scores ranging from zero (minimal disability) to 100 (severe disability). A higher score denoted a worse functional level.

Secondary Outcome Measurements

Pain-Related Fear (Kinesiophobia)

We assessed pain-related fear with the Turkish version Tampa Kinesiophobia Scale (TKS) developed by Miller et al. (Miller et al., 1991). The TKS is a 17-item Likert scoring scale that examines self-reported activity-related injury/re-injury and fear avoidance. The TKS has been validated in Turkish (Yilmaz et al., 2011) (with an internal consistency coefficient of 0.806). Total scores on this scale varied between 17–68, with a high score representing a high level of kinesiophobia.

Pain Sensitivity

We measured participants’ pressure pain thresholds (PPTs) with an algometer (Wagner Instruments, Greenwich, CT-USA) that utilized a 1-cm² rubber disc at the end of the device, inserted on the spinosus processes of L3 and deltoid muscle. Initially, two trials were performed on the extensor muscles of the forearm to familiarize the participant with the procedure. Next, participants were positioned lying prone on a massage table, and the measurement points were marked with a pen. The algometer was then positioned perpendicular to the skin, and a constant pressure was applied. The participant was asked to say “stop” when the feeling of pressure or discomfort became a clear feeling of pain. We made three measurements at 30-s intervals on each site and calculated the mean value for later data analysis. The deltoid muscle was chosen as the remote distal point from the lumbar region to evaluate general pain sensitivity (de Oliveira et al., 2013).

Central Sensitization

We used the Central Sensitization Inventory (CSI) to assess central sensitization (CS) (Mayer et al., 2012) and this questionnaire has been validated in Turkish (Düzce Keleş et al., 2021) (with an internal consistency coefficient of 0.93). The CSI defines whether an individual’s symptoms are related to CS. It consists of Part A, with 25 items that include somatic and emotional symptoms associated with CS, and Part B, which questions the respondent about previous diagnoses of central sensitization syndromes or related diseases. The frequency of symptoms is evaluated on a four-point Likert scale of zero (never) to 4 (always). The total score ranges from zero to 100, with high scores indicating a high CS.

Stress/Anxiety

We used the Turkish version of the Spielberger State-Trait Anxiety Inventory (STAI) to evaluate individuals’ self-reported stress levels, and we performed biochemical measurements related to stress (Öner & Le Compte, 1983). We measured participants’ self-reported stress levels with the STAI, a 40-item scale with responses given on a 4-point Likert scale for each item (Spielberger, 1983). The STAI consists of two subscales containing 20 items: a state anxiety scale (STAI-S) measuring a person’s anxiety at a particular moment and a trait anxiety scale (STAI-T) measuring how dispositionally anxious a person is across time and situations. The total score ranged from 20 to 80 was obtained from both scales, with high scores indicating high anxiety levels.

Additionally, after an overnight fast, we assessed Serum DHEA-S and cortisol levels from the antecubital venous blood obtained between 0830 and 0900 AM. Aliquots of 1.0 mL were stored in cryovials at −80C before cortisol and DHEA-S were assayed. Cortisol and DHEA-S concentrations were quantified by electrochemiluminescent (ECLIA) with a Roche Cobas e601 analyzer using an Elecsys kit (Roche Diagnostics, Indianapolis, IN).

Transversus Abdominis Muscle Activation

We measured transversus abdominis (TrA) activation with a stabilizer bio-feedback device (Chattanooga Group Inc, Hixson, TN, USA) with participants in the prone position. The device consists of three chamber pressure cells placed horizontally on the lower abdomen with the lower edge in line with (just below) the spina iliaca anterior superior and the unit’s center at the umbilicus (between SIAS and umbilicus). Cuff pressure was set at 70 mmHg, and patients were asked to contract the TrA while exhaling. Participants were instructed not to move their pelvis and spine during the measurement. We took three such measurements, and we recorded the average of these three measurements for later data analysis (de Paula Lima et al., 2012).

Quality of Life

We used the Nottingham Health Profile (NHP) to evaluate the participants’ self-reported subjective health status. The NHP, developed by Hunt et al. (Hunt et al., 1981), has 38 dichotomized (yes/no) items, with six dimensions for pain (P), physical activity (PA), energy (E), sleep (S), social isolation (SI), and emotional reaction (ER). The NHP was validated and found reliable in Turkish (Kücükdeveci et al., 2000) (Spearman correlation coefficients ranged from 0.70 to 0.92 for the six sections). Subscores of each dimension ranged from zero to 100, with a lower score denoting a better quality of life.

Adverse Events

Short-term muscle pain and tension were observed in some participants when they started the exercise programs. This short-term adverse result was expected, as study participants had a sedentary lifestyle. No serious adverse events were observed during the study.

Randomization and Anonymization

An independent researcher allocated participants to the three treatment conditions using Excel for Windows software (Microsoft Corporation, Redmond, WA) to generate randomization codes with a 1:1 allocation ratio. The randomization codes were placed in consecutively numbered, sealed, opaque envelopes to ensure the concealed allocation of participants to groups. Due to the nature of the interventions, it was not possible to anonymize group assignments to the therapist and participants. However, a biostatistician consultant who was unaware of the intervention groups carried out the data analysis.

Statistical Analysis

We represented descriptive statistics as means (and standard deviations) or medians (First and Third quartiles) and as frequency percentages (%) for continuous and categorical variables, respectively. We evaluated data distributions for the assumption of normality with the Shapiro-Wilk test, boxplot, histogram, and Q-Q plot. We compared the three independent groups with one-way analyses of variance (ANOVAs) or Kruskal-Wallis variance analysis, according to whether parametric assumptions of the data were satisfied or not. When the difference between the groups was significant, we used the Dunn-Bonferroni test for pairwise comparisons. For effect sizes, we calculated η2 by test statistic of KW (χ2) divided by n-1 (total sample-1) $(\frac{χ 2}{n - 1})$ . To interpret the effect sizes, we used the following guidelines (King et al., 2018):

• 0.01: Small effect size

• 0.06 = Medium effect size

• 0.14 = Large effect size

For categorical variables, we examined group differences with the Chi-Square or Fisher-Freeman-Halton tests. We studied the difference between the two dependent variables (first and second measurements) with the Wilcoxon test to determine the change over time in each group. We set the statistical significance level at p .05 for all tests. We performed all statistical analyses with IBM SPSS version 23.

Results

Participant Characteristics

A total of 49 participants were distributed across the three groups, with 15 in the PT group, 16 in the home exercise group, and 18 in the yoga group. The study flow diagram is shown in Figure 2.

Figure 2.

CONSORT Flow Diagram of the Study.

At baseline, there were no group differences in the participants’ ages, body mass index (BMI), or gender (p > .05). Additionally, there were no significant differences across groups on clinical measures except TrA muscle activation (p > .05). TrA muscle activation was lower in the yoga group compared to the other groups at baseline (p < .05). Detailed information about the participants’ baseline values on all parameters is given in Table 3.

Table 3.

Participants’ Baseline Characteristics.

Outcome measures	PTG (n = 15)	HEG (n = 16)	YG (n = 18)
Sociodemografic Characteristics	Median (IQR)	Median (IQR)	Median (IQR)	p
Age (year)	38 (31–49)	41 (33–45)	41 (34–46)	0.925
	n (%)	n (%)	n (%)
BMI
Underweight	0 (0)	1 (6.3)	0 (0)	0.696
Healthy weight	4 (26.7)	6 (37.5)	7 (38.9)
Overweight	7 (46.7)	8 (50)	8 (44.4)
Obesity	4 (26.7)	1 (6.3)	3 (16.7)
Gender
Female	8 (53.3)	6 (37.5)	10 (55.6)	0.530
Male	7 (46.7)	10 (62.5)	8 (44.4)	0.530
Clinical characteristics	Median (IQR)	Median (IQR)	Median (IQR)
Pain intensity-resting (VAS) (0-10)	2.7 (1.4–5.1)	3.25 (1–4.25)	2.75 (0–4.5)	0.817
Pain intensity-activity (VAS) (0-10)	8 (5.2–8.7)	7.1 (5.5–7.8)	6.45 (4.6–7.3)	0.296
Pain disability (ODI)	42 (30–52)	38 (30–47)	32 (20–48)	0.287
Pain sensitivity L3 spinosus processus (PPT)	6.92 (4.62–8.58)	5.19 (4.16–7.2)	6.3 (4.6–8.38)	0.283
Deltoid muscle R (PPT)	3.43 (2.26–6.26)	2.78 (1.94–4.28)	3.58 (2.96–4.24)	0.463
Deltoid muscle L (PPT)	4.15 (1.75–6.4)	2.6 (1.86–5.5)	3.24 (3.04–4.1)	0.509
Kinesiphobia (TSK)	42 (38–43)	41 (38.5–44)	39.5 (35–42)	0.182
Central sensitization (CSI)	28.5 (17–50)	35 (20.5–43.5)	24.3 (19.5–80.3)	0.766
STAI-I	36 (29–42)	36 (30–38)	35 (30–45)	0.929
STAI-II	44 (38–51)	40 (33–48)	40 (38–45)	0.623
Cortisol	11.73 (9.84–16.03)	9.9 (7.5–13.6)	8.1 (6.1–13.2)	0.178
DHEA-S	234.9 (125.9–372.7)	224.6 (118–254.2)	196.9 (106.2–266.3)	0.599
TrA muscle activation	5.4 (4–6.7)	5.2 (4.4–6.6)	3.4 (2.4–4.7)	0.011*
NHP-E	60.8 (0–63.2)	63.2 (9.2–100)	36.8 (18–45.2)	0.176
NHP-P	59.4 (29.8–100)	50.4 (16.1–80.2)	24.3 (16.8–80.2)	0.270
NHP-ER	24.5 (0–50.6)	19.2 (0–41.02)	13 (0–21.2)	0.207
NHP-SI	0 (0–41.4)	0 (0–42.5)	0 (0–4.8)	0.379
NHP-S	12.5 (12.5–55.9)	12.5 (0–52.7)	0 (0–34.2)	0.072
NHP-PA	31.2 (11.2–41.8)	32.8 (11.2–41.8)	31.07 (8.4–41.8)	0.676
NHP-TOTAL	198.9 (111.7–298.9)	188.8 (118–317.1)	106.03 (59.5–208.8)	0.08

Note. PTG: Physical Therapy Group, HEG: Home Exercise Group, YG: Yoga Group, ODI: Oswestry Disability Index STAI: State-Trait Anxiety Inventory, TSK: Tampa Scale for Kinesiophobia, CSI: Central Sensitization Inventory, DHEA: Dehydroepiandrosterone, TrA: Transversus Abdominis, NHP: Nottingham Health Profile, E: Energy, P: Pain, ER: Emotional Reaction, SI: Social Isolation, S: Sleeping, PA: Physical Activity, IQR: Interquartile Range, *p < .05. The values were given in bold to indicate that there was a statistically significant change in those values.

Primary Outcome Measures

There were no group differences on resting, activity VAS, or ODI at baseline or after treatment (p > .05). Relative to baseline values, we observed statistically significant improvement after treatment in all groups on these variables (p < .05). The change in resting and activity VAS scores over time was similar in each group (p > .05). The improvement in ODI scores over time was more significant in the PT group than in the yoga and HE groups (p < .05). Detailed information about these variables is given in Table 4.

Table 4.

Pre- and Post-treatment Values on Primary Outcome Variables.

		B.T. (a)	A.T. (b)	AT-BT	Wilcoxon signed-rank test	(a-b)
Pain intensity-resting (VAS) (0-10)	GROUPS	Median (IQR)	Median (IQR)	Median (IQR)	Z	p ⁱ
	PTG	2.7 (1.4–5.1)	0 (0–0.9)	2 (0.6–3.4)	−3.064	0.002
	HEG	3.3 (1–4.3)	0.3 (0–2.2)	1.1 (0.4–2.8)	−3.297	0.001
	YG	2.8 (0–4.5)	0 (0–1.3)	1.4 (0–4)	−3.062	0.002
	p ^a	0.817	0.328	0.602
	H (df1) = 1.015 (2), p = .602, η2 = 0.02
Pain intensity-activity (VAS) (0-10)	PTG	8 (5.2–8.7)	2 (0–5.2)	4.1 (3–5.5)	−3.409	0.001
	HEG	7.1 (5.5–7.8)	2.3 (1–5.8)	3.5 (1.4–4.8)	−3.44	0.001
	YG	6.5 (4.6–7.3)	1.7 (0–4.3)	3.2 (2.7–5.3)	−3.724	<0.001*
	p ^a	0.296	0.510	0.338
	H (df1) = 2.171 (2), p = .338, η2 = 0.05
Pain related disability (ODI) (0-100)	PTG	42 (30–52)	10 (4–24)	30 (16–36)	−3.409	0.001
	HEG	38 (30–47)	9 (5–33)	20 (11–27)	−3.519	<0.001*
	YG	32 (20–48)	13 (6–26)	12 (4–22)	−3.73	<0.001*
	p ^a	0.287	0.809	0.015
	H (df1) = 8.393 (2), p = .015, η2 = 0.17

Note. B.T: Before Treatment, A.T: After Treatment, PTG: Physical Therapy Group, HEG: Home Exercise Group, YG: Yoga Group, ODI: Oswestry Disability Index, IQR: Interquartile Range, pⁱ= (Wilcoxon), p^a = (Kruskal Wallis), p*<0.01. The values were given in bold to indicate that there was a statistically significant change in those values.

Secondary Outcome Measurements

There were no statistically significant group differences in TSK, L3 and deltoid R/L PPTs, CSI, STAI I and II, NHP total and sub-scores (E, P, SI, ER, PA), and cortisol and DHEA-S levels at baseline and after treatment (p > .05). However, TrA activation was lower in the yoga group than in the PT and HE groups at baseline (p < .05), but there was no difference between the groups on this measure after the treatments (p > .05). Moreover, in the after-treatment measurements, only the NHP-S variable showed a difference between the groups (p < .05). The score of this variable was lower in the yoga group than in the PT and HE groups.

From baseline to after-treatment, statistically significant improvements were found in all groups on pain sensitivity on the CSI, L3 and deltoid R/L and PPTs, in anxiety on the STAI I, in muscle TrA activation, and quality of life on the NHP Total, and NHP-E, P, PA sub-parameters scores (p < .05). On the STAI-II variable, we observed improvement in the PT and Yoga groups but not in the HE group. On NHP-ER and TSK variables, we observed improvement in the PT and HE groups but not in the yoga group. We observed improvement on the NHP-SI variable only in the HE group, while we observed a decrease in cortisol levels only in the PT group (p < .05). We saw no improvement on DHEA-S and NHP-S variables in any groups (p > .05). Detailed information about these variables is given in Table 5.

Table 5.

Pre- and Post-treatment Values on Secondary Outcome Variables.

		B.T. (a)	A.T. (b)	AT-BT	Wilcoxon signed-rank test	(a-b)
	GROUPS	Median (IQR)	Median (IQR)	Median (IQR)	Z	p ⁱ
STAI I	PTG	36 (29–42)	29 (25–32)	7 (3–13)	−3.186	0.001
	HEG	36 (30–38)	32 (24–37)	6 (2–9)	−2.135	0.033
	YG	35 (30–45)	31 (29–38)	3 (2–5)	−2.252	0.024
	p ^a	0.929	0.368	0.253
	H (df1) = 2.727 (2), p = .253, η2 = 0.05
STAI II	PTG	44 (38–43)	37 (34–46)	5 (2–12)	−2.446	0.014
	HEG	40 (33–48)	38 (34–46)	3 (1–8)	−0.944	0.345
	YG	40 (38–45)	38 (34–42)	4 (1–6)	−2.325	0.02
	p ^a	0.623	0.973	0.412
	H (df1) = 1.775 (2), p = .412, η2 = 0.03
TSK	PTG	42 (38–43)	35 (32–41)	7 (2–12)	−2.927	0.003
	HEG	41 (38.5–44)	35.5 (32.5–39)	5 (1–8)	−2.799	0.005
	YG	39.5 (35–42)	38.5 (29–42)	3 (1–6)	−1.852	0.064
	p ^a	0.182	0.878	0.136
	H (df1) = 3.985 (2), p = .136, η2 = 0.08
Pain sensitivity (PPT)L3 (lokal)	PTG	6.92 (4.62–8.58)	10.08 (6.88–12.78)	2.26 (1.18–4.08)	−2.970	0.003
	HEG	5.19 (4.16–7.2)	7.76 (5.6–13.74)	2.14 (1.84–7.36)	−3.237	0.001
	YG	6.3 (4.6–8.38)	11.7 (8.76–14.36)	4.08 (2.48–7.38)	−3.549	<0.001*
	p ^a	0.283	0.158	0.121
	H (df1) = 4.225 (2), p = .121, η2 = 0.09
Deltoid muscle R (distant)	PTG	3.43 (2.26–6.26)	5.04 (2.6–9.32)	2.32 (1.4–3.46)	−3.061	0.002
	HEG	2.78 (1.94–4.28)	3.74 (2.98–5.2)	1.39 (0.76–1.98)	−2.166	0.03
	YG	3.58 (2.96–4.24)	6.23 (4.74–7.96)	3.3 (1.36–4)	−3.432	0.001
	p ^a	0.463	0.102	0.210
	H (df1) = 3.124 (2), p = .21, η2 = 0.07
Deltoid muscle L (distant)	PTG	4.15 (1.75–6.4)	5.98 (2.22–8.2)	1.68 (1.11–2.75)	−3.059	0.002
	HEG	2.6 (1.86–5.5)	3.54 (2.52–6.34)	1.42 (1.28–2.48)	−1.978	0.048
	YG	3.24 (3.04–4.1)	6.06 (4.6–7.08)	2.36 (1.86–3.38)	−3.527	<0.001*
	p ^a	0.509	0.170	0.373
	H (df1) = 1.974 (2), p = .373, η2 = 0.07
CSI	PTG	28.5 (17–50)	9 (4–24)	17 (10–24)	−3.297	0.001
	HEG	35 (20.5–43.5)	16 (5–31)	11 (6–18)	−3.353	0.001
	YG	24.5 (20–37)	11 (5–19)	11 (6–20)	−3.726	<0.001*
	p ^a	0.766	0.888	0.339
	H (df1) = 2.613 (2), p = .339, η2 = 0.04
Cortisol level	PTG	11.7 (9.8–16.03)	10.3 (8.2–13.2)	2.8 (0.4–5.3)	−2.158	0.031
	HEG	9.8 (7.5–13.6)	11.1 (8.2–13.9)	2.4 (1.6–5.3)	−0.659	0.51
	YG	8.08 (6.06–13.2)	7.7 (7.2–12.1)	3.8 (0.6–5.7)	−0.341	0.733
	p ^a	0.178	0.275	0.771
	H (df1) = 0.521 (2), p = .771, η2 = 0.01
DHEA(S) level	PTG	234.9 (125.9–372.7)	233 (98.7–477.8)	15.5 (3.1–39.2)	−0.114	0.91
	HEG	224.6 (118–254.2)	203.9 (155–259.5)	33.4 (14.6–41.3)	−0.094	0.925
	YG	196.9 (196.2–266.3)	185.1 (122.2–256.5)	18.7 (14.6–31.3)	−0.682	0.496
	p ^a	0.599	0.651	0.585
	H (df1) = 1.1 (2), p = .577, η2 = 0.02
TrA activation	PTG	5.4 (4–6.7)	6.7 (4.7–8.7)	1.3 (0.6–2.3)	−2.03	0.042
	HEG	5.2 (4.4–6.6)	7.4 (6–8.4)	1.7 (1–3.3)	−2.985	0.003
	YG	3.4 (2.4–4.7)	6.4 (5–7.4)	2.9 (1.9–3.3)	−3.472	0.001
	p ^a	0.011	0.340	0.111
	H (df1) = 4.379 (2), p = .111, η2 = 0.09
NHP-E	PTG	60.8 (0–63.2)	0 (0–24)	24 (0–60.8)	−2.67	0.008
	HEG	63.2 (18.4–100)	0 (0–43.6)	36.8 (0–51.3)	−2.947	0.003
	YG	36.8 (24–39.2)	0 (0–24)	24 (0–36.8)	−2.643	0.008
	p ^a	0.176	0.979	0.473
	H (df1) = 1.499 (2), p = .031, η2 = 0.03
NHP-P	PTG	59.4 (29.8–100)	11.2 (0–36)	40.2 (18.4–53.1)	−3.17	0.002
	HEG	50.4 (21.8–80.3)	10.9 (0–50.4)	30.5 (8.9–51.7)	−2.859	0.004
	YG	24.3 (19.5–80.3)	2.9 (0–20.2)	20.2 (0–46.4)	−3.111	0.002
	p ^a	0.27	0.391	0.448
	H (df1) = 1.606 (2), p = .033, η2 = 0.03
NHP-ER	PTG	24.5 (0–50.6)	0 (0–12.01)	17.7 (0–36.6)	−2.803	0.005
	HEG	19.2 (0–40.5)	0 (0–7.8)	12.01 (0–27.8)	−2.805	0.005
	YG	13 (0–21.2)	0 (0–7.2)	10.9 (0–19.8)	−1.957	0.05
	p ^a	0.207	0.552	0.406
	H (df1) = 1.801 (2), p = .031, η2 = 0.03
NHP-SI	PTG	0 (0–41.4)	0 (0–0)	0 (0–20.1)	−1.289	0.197
	HEG	0 (0–42.4)	0 (0–0)	0 (0–38.4)	−2.197	0.028
	YG	0 (0–0)	0 (0–0)	0 (0–0)	0	1
	p ^a	0.379	0.774	0.118
	H (df1) = 4.281 (2), p = .118, η2 = 0.04
NHP-S	PTG	12.6 (12.6–55.9)	12.6 (0–28.7)	12.6 (0–27.3)	−1.023	0.306
	HEG	12.6 (0–49.7)	12.6 (0–12.6)	0 (0–24.5)	−1.859	0.063
	YG	0 (0–34.3)	0 (0–12.6)	0 (0–27.3)	−1.183	0.237
	p ^a	0.072	0.021	0.537
	H (df1) = 1.242 (2), p = .537, η2 = 0.02
NHP-PA	PTG	31.3 (11.2–41.9)	0 (0–11.2)	21.4 (9.3–31.1)	−3.059	0.002
	HEG	32.8 (11.2–41.9)	11.2 (0–31.8)	15.5 (0–21.7)	−2.584	0.01
	YG	31.07 (11.2–41.9)	11.2 (0–11.2)	10.9 (0–30.7)	−3.065	0.002
	p ^a	0.676	0.385	0.613
	H (df1) = 0.979 (2), p = .613, η2 = 0.02
NHP-TOTAL	PTG	198.9 (111.8–298.9)	62.3 (12.6–117.5)	96.7 (51.6–171.9)	−3.351	0.001
	HEG	188.8 (121.1–292.4)	38.6 (14.8–163.01)	86.6 (36.4–194.9)	−3.464	0.001
	YG	106.04 (60.4–205.1)	40.7 (11.2–59.4)	56.4 (39.2–100.6)	−3.574	<0.001*
	p ^a	0.08	0.487	0.247
	H (df1) = 2.797 (2), p = .247, η2 = 0.05

Note. B.T: Before Treatment, A.T: After Treatment, PTG: Physical Therapy Group, HEG: Home Exercise Group, YG: Yoga Group, STAI: State-Trait Anxiety Inventory, TSK: Tampa Scale for Kinesiophobia, CSI: Central Sensitization Inventory, DHEA: Dehydroepiandrosterone, TrA: Transversus Abdominis, NHP: Nottingham Health Profile, E: Energy, P: Pain, ER: Emotional Reaction, SI: Social isolation, S: Sleeping, PA: Physical Activity, IQR: Interquartile Range, pⁱ= (Wilcoxon), p^a = (Kruskal Wallis), p*<0.01. The values were given in bold to indicate that there was a statistically significant change in those values.

Discussion

Our primary objective in the current study was to assess the impact of physical therapy, home exercises, and yoga on pain intensity and pain-related disability. Additionally, our secondary aim was to explore the influence of these exercise interventions on measures of pain-related fear, pain sensitivity, central sensitization, stress levels, and overall quality of life.

Primary Outcomes Measures: Pain and Pain-Related Disability

PT and exercises are widely used to improve pain and function in individuals with LBP. In past research, motor control/core stability, aerobic exercise, stretching or strength exercises, yoga, and Pilates have effectively managed LBP (Carneiro & Rittenberg, 2010; Meng & Yue, 2015). We applied yoga, PT, and a HE program. While these three approaches were each similarly effective on pain, we observed more functional improvement in the PT group. Most past comparative studies of yoga, PT, or exercise approaches have revealed similar effects on participants’ pain and function (Michalsen et al., 2021; Saper et al., 2017; Ulger et al., 2023). The similar decrease in pain severity in all three groups could be explained by the fact that the exercises applied in the study included movements to improve strength and flexibility. However, the way they were taught and practiced was different (Gilliam et al., 2023). While yoga increased the strength, endurance, and flexibility of the spinal stabilizing muscles, leading to better control of postural stability and ultimately reducing loading of the spine and pain level, participants in the SSE contracted the TrA muscle, which leads to an increase in intra-abdominal pressure transferred to the multifidus muscle via the thoracolumbar fascia, thereby increasing lumbosacral stability which also leads to decreased load on the spinal structures and pain levels. Both yoga and SSE decreased pain during activity, leading to functional improvement by decreasing activity limitations.

The similar improvement in pain severity in all three treatment groups may be related to exercise approaches in all groups. The HE group was also given the SSE to the PT group in the form of home exercises with an illustrated booklet. In addition, the exercises were progressed by calling the individuals every week and inviting them to the clinic for weekly check-ups. These factors may have increased the effectiveness of the home exercise program and made it as effective as the other groups. The more significant improvement in ODI score in the PT group may have been due to the application of Hotpack and TENS in addition to SSE in this group.

TENS is thought to reduce pain perception through stimulation of larger non-nociceptive A-fibers suggested by the Gate Control Theory, the possibility of segmental inhibition of cells in the substantia gelatinosa on the “pain gate,” and increasing endorphin levels (Itoh et al., 2008). Superficial heat agents likely decreased paravertebral muscle spasm, relaxing myofascial tissue by increasing local circulation (Lewis et al., 2012). SSE and these physiologic effects of TENS and Hotpack applications may have led to a more significant improvement in ODI scores in the PT group.

Secondary Outcomes Measures

Pain Related Fear

Others reported that exercise approaches reduce fear avoidance behaviors and kinesiophobia in individuals with LBP (Hanel et al., 2020). We showed that kinesiophobia levels improved after treatment in PT and HE groups, but there was no statistically significant decrease in kinesiophobia in the yoga group. On the TSK, a score of 37 and above is expressed as kinesiophobia. We found kinesiophobia scores to be above this value in all three of our groups at baseline, however this score was higher in the PT and HE groups than in the yoga group. Klaber Moffet et al. stated in their study that individuals with cLBP with high kinesiophobia benefited more from the exercise program than typical general practitioner care, while this was not true for low fear-avoiders (Moffett et al., 2004). In this context, we suggest that varying kinesiophobial levels but the same exercise approach (SSE) may experience different treatment-induced improvement.

Pain Sensitivity and Central Sensitization

Many studies found significant dysfunction in descending inhibitory pathways and widespread hyperalgesia in chronic pain conditions, including LBP (Graven-Nielsen, 2022; Henry et al., 2011; Meeus & Nijs, 2007; Nijs et al., 2021). Persistent CS negatively affects treatment outcomes and QoL in patients with LBP. Therefore, it is essential to evaluate the presence of CS involvement in LBP in order to organize appropriate and personalized treatments. It continues to be challenging to detect and measure hypersensitivity in clinical practice, and no consensus has been reached on which tools are best for assessing cLBP. Along with self-reported outcome measures, quantitative sensory testing (QST) is used to examine altered sensory processing, including signs of CS involvement. Among the QST parameters, PPT is the most frequently appraised and can be used to evaluate peripheral and central sensitization (Suzuki et al., 2022).

The number of studies evaluating the effect of varied treatment approaches on CS involvement in individuals with cLBP is limited. Studies have shown that Cognition-Targeted Motor Control Training, Soft-Tissue Mobilization, Pain Neuroscience Education, and High-intensity training approaches reduce CS symptoms assessed by CSI (Bodes Pardo et al., 2018; Verbrugghe et al., 2023). In the current study, reductions on CSI scores were observed in all treatment groups. However, it would be helpful to interpret these results carefully. In our study, according to CSI, mild CS symptoms were present only in the HE group, while the values in the other two groups were at the subclinical level. A study stated that HIT improves the largest symptoms of CS in persons with cLBP (Verbrugghe et al., 2023). This effect is in persons with clinically relevant baseline CSI scores. For this reason, the effectiveness of these approaches should be evaluated in further studies in individuals with a cut-off point score above 40. However, these beneficial effects in our study are promising for future studies.

In our study, PPT values improved after treatment in all three groups in addition to this positive effect on CS symptoms. In studies evaluating pain sensitivity in individuals with LBP, the instruments, methods, and areas of PPT examination were not standardized. However, some investigators showed that various treatment and exercise approaches increased PPT values (Suzuki et al., 2022). In our study, both local and remote PPT values improved after treatment. Although the mechanisms of action on pain sensitivity still need to be made clearer, some ideas are suggested. Pain modulation is regulated by the interactions between neurophysiological processes, motor/spinal control-movement strategies, and individual pain experience (Paungmali et al., 2017). Since there is a change in the pain modulation system from peripheral to central mechanisms, it may be possible to control peripheral nociceptive input in chronic pain conditions with sufficient motor/spinal control movement strategies. Eventually, central nervous system sensitivity may be reduced. In our study, SSE and yoga applied with breathing techniques may have positively affected pain perception and sensitivity through this mechanism.

Stress/Anxiety

Physical and psychological stress are among the risk factors for cLBP. Stressful and painful situations can cause catabolic processes through the nervous and endocrine systems. Stress can be assessed in many ways, and assessments in these pathways are often classified as subjective or objective. Subjective measures include perceived stress self-reported measures, while objective measures include biochemical markers (Riley & Park, 2015). Accordingly, we preferred to evaluate stress with both the STAI, a self-report measure, and by measuring cortisol and DHEA-S levels, objective assessments.

There has been a rapidly growing literature proposing that yoga, PT, and other exercise approaches can effectively reduce LBP perception, disability, stress, and serum levels of stress-related biomarkers. Most recent investigators evaluating yoga effects found high evidence of positive effects on stress biomarkers (Riley & Park, 2015). We focused on breathing and relaxation in yoga while also practicing improved self-awareness of mind and body, encouraging participants to develop the ability to relax and focus, yielding reduced stress. However, these methods were not associated with statistically significant changes in stress related blood levels. There have been sufficient studies investigating the effect of different exercise and physiotherapy approaches on cortisol and DHEA-S values, but more studies are needed to examine the impact of exercise on these neuroendocrine factors in individuals with cLBP. Some researchers evaluated the effect of yoga and stretch exercises on saliva cortisol and DHEA values in individuals with cLBP and found no differences between these methods, presuming that these participants were already psychologically healthy and could not make significant further gains through yoga practice (Carlson et al., 2004; Corey et al., 2014). There have been only limited studies investigating the effect of SSE on stress-related biomarkers, such as cortisol and DHEA. Paungmali et al. investigated the immediate effects of SSE on cortisol levels and detected no change in cortisol levels after 15 minutes of exercise (Paungmali et al., 2018). These authors stated that the effect of SSE on pain relief may be explained by the endogenous opioid mechanism rather than the stress-related analgesia mechanism. Chatzitheodorou et al. researched cortisol levels in individuals with cLBP who received 12-week high-intensity aerobic exercises, and they found no significant difference in cortisol levels from this treatment, attributing this finding to weak and inconsistent benefits, as seen by prior literature and by a small participant sample size (Chatzitheodorou et al., 2007). In a meta-analysis, Barros dos Santos et al. reported inconsistent benefits and some tendency to increase cortisol levels from physical exercises, including Qigong, spinal stabilization, and from aerobic exercises (Barros dos Santos et al., 2021).

In our study, STAI scores decreased in all groups after treatment. While we observed no effect of these approaches on biochemical measurements on DHEA-S, we observed a significant reduction in cortisol levels in the PT group only. More significant changes in cortisol levels in the PT group may be due to pain relief, associated with combining a superficial heat agent, TENS, and SSE. However, it is important to interpret our study’s results carefully. One prior investigator reported the cut-off score as 41 for STAI-I and 44 for STAI-2 (Ercan et al., 2015). In this context, our participants’ anxiety levels were low. Thus, it would be important for future investigators to evaluate STAI scores after treatment in individuals with higher anxiety levels. Similarly, the effects of treatments on cortisol and DHEA-S levels should be evaluated in individuals whose morning cortisol levels are higher than those of our participants.

Transversus Abdominis Activation

Few prior researchers compared the effects of yoga and SSE on TrA activation. In a previous study (Ulger et al., 2023), we observed that yoga and SSE was related to TrA activation; and this effect was higher in the SSE group. However, in this study, we observed similar improvement in TrA activation in all groups. The primary mechanism of SSE is the re-education of TrA muscle activation, and this is expected to develop in the PT and HE groups in which these exercises were applied. Very few researchers have examined the effects of yoga techniques on core stability, though Omkar and Vish stated that yoga techniques such as uddhayana bandha and nouli can increase core stabilization (Omkar, Vishwas, & Tech, 2009). If we consider the diaphragm’s role and function as a core stabilizer muscle, combining breathing exercises with asana and relaxation exercises may have improved spinal stability and TrA activation.

Quality of Life

CLBP often causes pain and disability, negatively affecting the QoL of individuals. Prior investigators have shown that PT and different exercise approaches benefited pain and disability symptoms and improved QoL. In a systematic review and meta-analysis there was no difference in the effects of yoga and PT exercise interventions on physical and mental QoL (Zhu et al., 2020). In our study, NHP total, NHP-E, NHP-P, NHP-ER, and NHP-PA parameters showed similar improvements across all treatment groups, though NHP-SI improved only in the HE group, and there was no improvement in the NHP-S subparameter. We think the positive effects of all these approaches on pain perception, disability, and stress contributed to improved QoL. Initially, SI scores were low in all groups, meaning that the level of negative effects was low. In addition, the NHP assesses QoL for the general population and is not specifically designed for the LBP population. Since social isolation is also subjective, improvement on this variable may not have occurred in all groups. Performing exercises with regular weekly controls in the HE group may have benefited participants by encouraging their socialization. Since the NHP-S parameter was low in all groups at baseline, it may have difficult to show a beneficial effect of exercise approaches on this parameter.

While we hypothesized that there would be different effectiveness of yoga, physical therapy, and home exercises on these variables, we found no group differences except with respect to pain-related disability. All interventions in our study resulted in decreased stress, pain intensity, pain sensitivity, central sensitization, and both improved function and improved QoL; there was no singularly superior approach between these interventions. Our findings are consistent with past literature, which found comparable results across conservative approaches to treating cLBP. With this in mind, we should note that most past research focused on pain and disability. However, pain differs from nociception alone, and it includes emotional, cognitive, and behavioral elements. Therefore, we believe that the results of our study, evaluating different dimensions of pain, such as pain-related fear, anxiety, pain sensitivity, central sensitization, and quality of life (QoL), in addition to pain and disability, provide important new data. The preferred conservative approach for managing cLBP should consider the relevant factors identified during history and examination, patient preferences and beliefs, the therapist’s training and experience, and the feasibility and sustainability of the treatment in the specific context of the patient.

Limitations and Directions for Further Research

Among several limitations of this study, a main problem was measuring treatment effects with blood markers to provide information on the impact of exercise on stress-related neuroendocrine mechanisms. Due to limited funding for the high cost of blood sample analyses, we could not perform an a priori analysis, and we had to rely on our small sample size, for which generalization to other samples may be limited. Furthermore, we assessed these outcomes only over a short term (6 weeks). Future investigators should evaluate the efficacy of longer-term treatment protocols (12 weeks and above) in larger samples. Additionally, we did not assess the long-term follow-up results of these interventions and cannot attest to any long-term safety concerns that may emerge afterward. Systematic reviews and meta-analyses examining the safety of these approaches in individuals with cLBP have reported minor (temporary pain exacerbations, etc.) or no adverse events (Cramer et al., 2015; Saragiotto et al., 2016). However, it is worth noting that only some of the studies included here evaluated the long-term efficacy of these approaches and reported these events. Therefore, in future studies, adequate and guideline-compliant reporting of adverse events would be beneficial in interpreting the efficacy and safety profiles of these approaches. As stated earlier, we could not keep therapists unaware of which participants were receiving which intervention, and our participants showed low CS involvements and stress levels. In future studies, investigators might evaluate these approaches in individuals with high levels of CS involvement and stress. In addition, although we focused on individuals with cLBP, our evaluation of different dimensions of pain and our results may provide insight and guidance for other chronic pain populations, such as neck pain and fibromyalgia. Finally, we would like to emphasize that including objective outcome measures in future studies is important to determine the effectiveness of treatment approaches.

Conclusions

While numerous prior studies have highlighted the effectiveness of yoga in addressing musculoskeletal disorders, we uniquely focused solely on yoga as an intervention for cLBP. Remarkably, we showed similar outcomes between yoga and physiotherapy techniques. We found SSE efficacious for alleviating pain and stress, improving functionality, and elevating overall quality of life when used either under the guidance of a physiotherapist or as a home-based regimen. Given the comparable impacts of yoga and SSE among individuals with cLBP, the SSE regimen holds promise as a viable home-based program for patients unable to engage in exercise sessions actively. Meanwhile, our findings make evident that all these approaches yielded favorable effects on pain reduction, improved disability, modulating the nervous system’s sensitization states, and mitigating anxiety/stress.

Footnotes

Declaration of Conflicting Interests

The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Funding

The author(s) received no financial support for the research, authorship, and/or publication of this article.

ORCID iD

Muzeyyen Oz

Author Biographies

Muzeyyen OZ PhD in Physical Therapy and Rehabilitation by Hacettepe University. She continues her work in the field of spinal health.

Ozlem Ulger PhD in Prosthetics, Orthotics and Biomechanics by Hacettepe University. Professor at Hacettepe University Faculty of Physical Therapy and Rehabilitation. She continues her work in the field of spinal health.

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