J Rehabil Med 2015; 47: 167–173

ORIGINAL REPORT

Cost-effectiveness of Early Interventions for Non-specific

Low Back Pain: A Randomized Controlled Study Investigating
Medical Yoga, Exercise Therapy and Self-care Advice

Emmanuel Aboagye, MSc, Malin Lohela Karlsson, PhD, Jan Hagberg, PhD and
Irene Jensen, PhD
From the Intervention and Implementation Research Unit, Institute of Environmental Medicine, Karolinska Institutet,
Stockholm, Sweden

Objective: To evaluate the cost-effectiveness of medical yoga mon reasons why working adults take days off work or become
as an early intervention compared with evidence-based ex- disabled (3). Thus the cost, both economic and human, of LBP
ercise therapy and self-care advice for non-specific low back can be high if the appropriate early treatment is not sought (4).
pain. There are a variety of therapies for managing LBP, but there
Design: Randomized controlled trial with a cost-effective- is limited knowledge about their effectiveness with regards to
ness analysis. improvement in health-related quality of life (HRQL). Exercise
Subjects: A total of 159 participants randomized into the therapy is one of the commonly used interventions for managing
medical yoga group (n = 52), the exercise therapy group LBP as an alternative to usual care (i.e. evidence-based advice).
(n = 52) and the self-care advice group (n = 55). Exercise therapy can encompass many types of interventions
Methods: The health outcome measure EQ-5D was applied
with regards to method and design (5). However, it has been
to measure quality of life data combined with cost data col-
shown that supervised exercise therapy, including individually
lected from treatment groups from baseline to 12 months
designed stretching or strengthening, have positive effects on
follow-up. Outcome measure was health-related quality of
pain and back function in people with non-specific LBP (6).
life (HRQL). Incremental cost per quality adjusted life year
(QALY) was also calculated. Cost-effectiveness analysis was Some complementary and alternative medicine (CAM)
conducted primarily from the societal and employer per- therapies have been used for LBP (7, 8). Yoga can also be used,
spectives. mainly for pain management (9). In addition to its suitability
Results: Medical yoga is cost-effective compared with self- for a number of conditions, medical yoga has been shown to
care advice if an employer considers the significant im- alter the experience of pain and to have positive and sustain-
provement in the HRQL of an employee with low back pain able effects on back function (9). However, screening generally
justifies the additional cost of treatment (i.e. in this study precedes treatment with medical yoga, so that training and
EUR 150). From a societal perspective, medical yoga is a physical posture instructions can be individually designed.
cost-effective treatment compared with exercise therapy and The significant outcomes in studies that have evaluated the
self-care advice if an additional QALY is worth EUR 11,500. effectiveness of yoga for managing LBP include: reduced pain
Sensitivity analysis suggests that medical yoga is more cost- intensity and greater improvement in physical and functional
effective than its alternatives. disabilities (10, 11). However, there has been little research
Conclusion: Six weeks of uninterrupted medical yoga thera­ into improvement in HRQL from early treatment and the cost-
py is a cost-effective early intervention for non-specific low effectiveness of yoga for LBP. In a multicentre randomized
back pain, when treatment recommendations are adhered to. control trial, yoga compared with usual care was shown to
Key words: medical yoga; low back pain; cost-effectiveness improve quality of life and be cost-effective among patients
analysis; occupational health services. with chronic LBP (12). It is therefore imperative to conduct
J Rehabil Med 2015; 47: 167–173 studies on the effects and cost-effectiveness of medical yoga
therapy as an early preventive intervention for LBP.
Correspondence address: Malin Lohela Karlsson, Karolinska
Institutet, Intervention and Implementation Research Unit,
Nobels väg 13, Solna, Box 210, SE-171 77 Stockholm, Sweden. Aim
E-mail: [email protected] To evaluate the cost-effectiveness of medical yoga as an early
Accepted Aug 27, 2014; Epub ahead of print Nov 14, 2014 intervention for managing LBP compared with 2 evidence-
based interventions; exercise therapy and self-care advice.

Introduction Hypotheses
Low back pain (LBP) has been described as a recurring condition Our first hypothesis was that medical yoga will improve HRQL
and a costly public health problem (1, 2). It is one of the most com- more than exercise therapy and self-care advice, and, secondly,

© 2015 The Authors. doi: 10.2340/16501977-1910 J Rehabil Med 47

Journal Compilation © 2015 Foundation of Rehabilitation Information. ISSN 1650-1977
168 E. Aboagye et al.

that medical yoga is more cost-effective than either exercise questionnaire; and having a sufficient command of Swedish. Exclusion
therapy or self-care advice. criteria were: pregnancy; comorbidities that could affect the ability to
perform exercise; ongoing regular weekly yoga practice or strength
training; and ongoing sickness absences of 8 weeks or more.
Of the total of 310 people who responded to the OMPSQ screen-
Methods ing questionnaire, 138 were excluded because they scored less than
The study was a single-blinded randomized control trial with a 90 points (Fig. 1). The 172 subjects who remained were assessed for
12-month follow-up that compared medical yoga with exercise therapy eligibility and 13 were excluded at the enrolment stage for not fulfilling
and self-care advice. The participants were randomized to 1 of 3 inter- the inclusion criteria. The remaining 159 participants who qualified for
ventions after undergoing an initial medical examination to screen for inclusion were randomized to 1 of the 3 treatment groups, resulting
comorbidities and serious illnesses. The examination was performed in 52 in the medical yoga group, 52 in the exercise therapy group and
by back specialists. A block randomization was utilized using the pre- 55 in the self-care advice group that were included in the analysis.
randomization technique and participants were picked consecutively Data on participants’ adherence to treatment, back pain and sickness
by a research assistant. After randomization, the back specialist met absence were collected during the follow-up period via text messages
with the participants and gave them background information about the sent out once a week for 6 weeks, and then once a month until the
intervention they were being offered. Previous studies (13) have shown 12th month. Sickness absence was absence due to all types of illness.
that expectations of treatment and response levels differ depending
on, whether the treatment is physically or psychologically oriented. Outcome measurement
Therefore, the 2 training interventions (yoga and exercise therapies) The primary outcome was HRQL measured with EQ-5D at baseline and
were both presented as well-established training therapies, to improve each follow-up (6 weeks, 6 months and 12 months). This instrument
the level of participation and to equalize the participants’ expectations measures the individual’s health state on 5 scales: mobility, self-care,
of the treatment and its outcomes. During the assignment of study usual activities, pain/discomfort and anxiety/depression. The responses
participants to intervention groups, assessors (those collecting outcome were weighted with the time trade-off method, which gives quality
data) were blinded to group allocation and the patients were blinded adjusted life year (QALY) values anchored between 0 and 1, where
with respect to other intervention options. All researchers analysing 1 is a year lived in full health and 0 (zero) represents death (16). The
the results were blinded to group allocation until the analyses were Danish tariff was used since there were no time trade-off estimates
complete and the manuscript had been written. for the Swedish population (17).
Interventions Costs of intervention
Medical yoga was a Kundalini-based standardized programme per- The estimated costs were based on the number and type of activities in
formed in groups, twice a week for 6 weeks and led by an experienced each treatment group, the amount of resources consumed and duration
medical yoga instructor. Participants received a CD with instructions, of use of resources. The cost in the medical yoga group included the
and written information about the programme, and were encouraged to cost of the yoga trainer, the cost of the materials used and physician
perform the programme as often as possible between the medical yoga assessment (screening) cost based on the primary care reference cost
sessions. After 6 weeks, the participants were to carry on practicing per visit by a physician. Costs associated with the exercise therapy
medical yoga no less twice per week. included: the cost of physician assessment, the cost of the first visit
Exercise therapy was a 6-week individual, standardized strength to a physiotherapist and repeat visits, the cost of an exercise training
training programme followed up by an experienced physiotherapist in activity based on the market price if the participant received physical
groups once every second week. In the first week of intervention start, activity on prescription, the back book and an exercise ball. The cost
the participants and the physiotherapist met twice in order to individu- in the self-care advice group was based on physician assessment and
ally design the training programme. Participants were followed-up self-care advice as well as the back book. The intervention costs were
after 2, 4 and 6 weeks. Subsequently, participants were to continue incurred regardless of the number of classes participants attended
practicing the exercise therapy programme at least twice per week. after allocation to a treatment group. Therefore, participants were
In the evidenced based self-care advice group, individuals received assigned the same costs based on allocation to treatment group. All
brief oral recommendation from a back specialist to stay active and costs of resources were collected retrospectively. Discounting was
a booklet containing self-care advice. Brief advice to staying active not necessary as costs and consequences occurred within a year after
has been shown to have positive effects on pain and improvement in recruiting participants (18). The total cost of resources used in the
physical function among individuals with LBP (14). trial reflects 2011/2012 prices, since the follow-up period occurred
within this interval.
Ethical considerations
All 3 groups received treatment based on ethical grounds. The study Statistical and economic analysis
was approved by the Regional Ethics Committee (2010/108-31/3) HRQL was estimated using regression analysis. In order to evaluate
and registered in the clinicaltrials.gov protocol registration system the intervention effect on HRQL, the utility were adjusted for baseline
(NCT01653782). utility scores and the resulting coefficient for the treatment dummy
was stated as the mean incremental QALY (19). The adjustment was
Data collection important, since the baseline EQ-5D score tends to correlate with the
Participants were recruited through the Occupational Health Services follow-up scores of participants (19).
(OHS) and by advertisement in the local media in Sweden’s Stockholm Interactional effects between the treatment groups and the number
County. People of working age with neck/back pain were invited to of days a participant trained were also considered, since our initial
apply for participation in the study. Then, a screening questionnaire analysis showed that there was a strong interaction between treatment
was posted to those who responded to the invitation to participate in the group and training frequency per week. A generalized linear model
study. Those who scored 90 points or more, i.e. fulfilling the require- was used for dichotomous outcomes and a linear model for continuous
ments for psychosocial risk profile, on the Örebro Musculoskeletal outcomes to account for such strong interactional effects. For each
Pain Screening Questionnaire (OMPSQ) (15) were invited for further number of training days, a unique difference between treatment groups
physical examination. was calculated with corresponding confidence intervals. Baseline age
Inclusion criteria were: having non-specific LBP; age range 18–60 and mean number of training days were used as covariates in the model.
years; having scored 90 points or more on the OMPSQ screening The analyses were performed in SPSS version 20.

J Rehabil Med 47
 Cost-effectiveness of medical yoga for low back pain 169

The costs in the intervention groups were derived by multiplying

Screening (OMPSQ) (n=310)
the length of time used in the assessment, the number of resources
consumed and the total number of participants in one treatment group, Excluded (n=138)

Enrolment
and then summarized for each treatment group. The mean cost in
each treatment group was used to calculate the mean incremental Assessed for eligibility (medical examination) (n=172)
cost, i.e. the differences in the mean cost between medical yoga and
its comparators. Excluded (n=13
The cost-effectiveness of the interventions was calculated as the )
incremental cost-effectiveness ratio (ICER) and estimated using mean Baseline (n=159)
incremental cost and the adjusted mean incremental QALY. The analy-
sis was conducted from the societal perspective. The societal perspec-
Randomized (n=159)
tive included all costs associated with the intervention and production
loss as a result of sickness absence. Production losses resulting from

Allocation
sickness absences were estimated as the mean hourly earnings of the
Allocated to yoga Allocated to exercise Allocated to self-care
employee multiplied by the number of days off work. In addition to
Intervention (n=52) Intervention (n=52) Advice (n=55)
the hourly earnings (20), additional compensation-holiday allowances
(13%), labour (31.42%) and pension contributions (10%) paid on top
Fig. 1. Flowchart of participant selection process. OMPSQ: Örebro
of employee earnings were included. These payments in themselves
will not represent any additional consumption of resources from the Musculoskeletal Pain Screening Questionnaire.
standpoint of society. However, these earnings are included as costs to
society only as a proxy of lost productivity, i.e. reduced work produc- the medical yoga group, 46 years in exercise therapy and 44
tion due to sickness absences. The analysis was also performed from
the employer’s perspective including the intervention costs.
years in the self-care advice group.
Since uncertainty can arise about the use of, for instance, nega-
tive ICER in a cost-effectiveness analysis for decision-making (18). Outcome of the intervention
Incremental net benefit (INB) was also estimated. The INB is a linear
expression of the cost-effectiveness decision rule that can trace the net Descriptive data on overall HRQL and for the interaction term,
benefits of the intervention after accounting for the additional cost of i.e. training ≥ 2 times per week, are shown in Table II. Dif-
implementing an intervention. The INB was estimated by multiply- ferences in HRQL between individuals adhering to treatment
ing the adjusted incremental QALY by the willingness to pay less recommendation (i.e. training at least 2 times per week) and
the mean incremental cost (18). The INB provides evidence that an
those who were not are shown. Participants in the exercise
intervention is cost-effective if the net benefit is greater than zero (21).
The willingness to pay value assumed was EUR 11,500, equivalent therapy and self-care advice groups had higher mean EQ-5D
to SEK 100,000 per QALY, which is the lower limit consistent with scores at baseline than did individuals in the medical yoga
the recommendations of the Swedish National Board of Health and group. However, during each follow-up period individuals in
Welfare for a cost-effective intervention (22). the medical yoga group had higher mean scores than did those
in the exercise therapy and self-care advice groups. Therefore,
Sensitivity analysis of the economic evaluation
the baseline EQ-5D scores were used as a covariate for the
The sensitivity analysis focused on the productivity losses that resulted
from sickness absences. The cost of lost production is estimated by adjustment.
multiplying the daily wage rate by the number of absent days (18). Statistical analyses revealed that medical yoga had a
However, extant research suggests that this conventional approach may significant (p = 0.031) and better effect on HRQL than did
underestimate the true cost of lost production from sickness absence evidence-based self-care advice, taking into account the
(23). Therefore, in estimating the cost of absenteeism, the difficulty
interaction effect (i.e. training 2 times/week or more). The
of finding a perfect substitute for the absent worker, the role of the
absent employee in teamwork, and the time-sensitivity of employees’ difference between medical yoga and exercise therapy was not
output should be taken into consideration. One-way sensitivity analysis significant (p = 0.574) even when controlling for the interaction
was used to estimate the total absenteeism cost by multiplying num-
ber of days off work by the median multiplier 1.28 times the mean
daily wage rate (23). The median multiplier was used because of the
nature and diversity of jobs that participants were engaged in at the Table I. Description of study participants
beginning of the study. Yoga Exercise Advice
Variables (n = 52) (n = 52) (n = 55)
Sex, female, n (%) 37 (71.7) 32 (61.5) 44 (80)
Results Age, years, mean (SD) 46.9 (9.6) 46.3 (9.3) 43.9 (11.7)
Education, n (%)
Description of participants at baseline Elementary/junior high 25 (47) 29 (55.8) 32 (58.1)
The total number of participants was 159 (Fig. 1) and the Higher education 27 (51) 23 (44.2) 21 (36.8)
response rate for the 3 follow-up periods after the baseline as- Lived in Sweden, n (%)
Always 37 (69.8) 38 (73) 35 (63.6)
sessment was 89% for medical yoga, 69% for exercise therapy < 5 years 2 (3.8) 1 (1.9) 1 (1.8)
and 63% for self-care advice. All participants were of working > 5 years 50 (96.2) 51 (98.1) 52 (94.5)
age and were at the beginning of the study working and not Additional pain sites, n (%)
on sick leave. The proportion of women differed somewhat Neck pain 34 (64) 34 (65) 36 (63.2)
between the groups (Table I). The mean age was 47 years in Upper back pain 27 (51) 28 (54) 26 (45.6)

J Rehabil Med 47
170 E. Aboagye et al.

Table II. Health outcome according to treatment adherence within treatment groups
Medical yoga (n = 52) Exercise therapy (n = 52) Self-care advice (n = 55)
< 2 times/week ≥ 2 times/week < 2 times/week ≥ 2 times/week < 2 times/week ≥ 2 times/week
HRQL, mean (SD)
Baseline 0.72 (0.20) 0.71 (0.20) 0.76 (0.14) 0.74 (0.17) 0.70 (0.20) 0.73 (0.22)
6 weeks 0.64 (0.31) 0.80 (0.11) 0.81 (0.08) 0.78 (0.16) 0.74 (0.11) 0.70 (0.22)
6 months 0.77 (0.17) 0.77 (0.15) 0.81 (0.08) 0.76 (0.21) 0.72 (0.21) 0.70 (0.28)
12 months 0.73 (0.21) 0.79 (0.14) 0.75 (0.16) 0.79 (0.13) 0.73 (0.15) 0.75 (0.23)
p-values < 2 times/week are 0.177 and 0.073 for comparing medical yoga with exercise therapy and self-care advice, respectively.
p-values ≥ 2 times/week are 0.574 and 0.031 for comparing medical yoga with exercise therapy and self-care advice, respectively.
HRQL: health-related quality of life; SD: standard deviation.

effect. Thus our first hypothesis, which says medical yoga will Table III presents the mean number of days of sickness
improve HRQL more than will exercise therapy and self-care absence at the 1-year follow-up, separated by the interaction
advice, is partly verified. break-point. For the overall group, the average participant in
the medical yoga group reported 12.4 days (standard devia-
Cost analysis of interventions tion (SD) 17.1) off work as a result of LBP during the 1-year
The direct and indirect costs (i.e. production losses) of each period, whereas for the exercise therapy and self-care advice
intervention, are shown in Table III. The cost of resources groups the sickness absence numbers were higher: 22.4 days
used in each treatment group differed depending on the type of (SD 41.6) and 29.6 days (SD 67.0), respectively.
health personnel, the length of time used in assessing partici- The mean cost of productivity lost (Table III) from sickness
pants and the amount of resources used. In an OHS setting, the absence was, EUR 1,627 in the medical yoga group, EUR 2,941
mean cost of combined preliminary assessment by a physician, in the exercise therapy group and EUR 3,900 in the self-care
other health personnel, and materials used, was estimated at advice group. This implies that the mean societal cost was
EUR 255 for those who were offered medical yoga, EUR 461 EUR 1,519 and EUR 2,124 more in the exercise therapy and
for those in the exercise therapy group, and EUR 106 for those self-care advice groups, respectively, than the mean societal
in the self-care advice group (Table III). cost in the medical yoga group.

Cost-effectiveness of the intervention

Table III. Intervention costs by treatment group
Employer’s perspective. The cost-effectiveness of the interven-
Cost per intervention, EUR
tions is shown in Table IV. From the employer perspective,
Medical yoga Exercise Advice medical yoga costs EUR 150 more than self-care advice,
(n = 52) (n = 52) (n = 55)
yielding an ICER of EUR 4,984 per QALY. This implies that
Cost items medical yoga is more expensive than self-care advice, but is
Direct costs
beneficial, if adherence to the recommendations is taken into
Physician assessment 3,588 3,588 3,795
Physician advice – – 1,898 account. Thus medical yoga can be considered cost-effective
Yoga trainer 9,568 – – if an employer considers that the improvement in HRQL of
Physiotherapists – 19,061 – an employee justifies the additional resources required for
Material/equipment 120 1,316 127 medical yoga treatment.
Total direct costa 13,276 23,965 5,819
Mean direct cost 255 461 106
Indirect cost Table IV. Incremental cost effectiveness ratio (ICER) of medical yoga
Cost of productivity lost 84,591 152,907 214,529 compared with exercise therapy and self-care advice
Mean productivity lost 1,627 2,941 3,900
Total societal costb 97,867 176,872 220,348 Employer’s Societal
Mean societal cost 1,882 3,401 4,006 Medical yoga vs self-care perspective perspective
Sickness absence (days) after 1-year follow-up advice Mean (95% CI) Mean (95% CI)
Training days/week Incremental cost 150 –2,124
< 2 times 24 (19) 31 (30) 22 (43) Incremental QALY 0.036 (–0.033; 0.11) 0.036 (–0.033; 0.11)
≥ 2times 9 (15) 18 (50) 52 (108) ICER (cost per QALY) 4,984 Cost-effective
a
Total direct cost of intervention (i.e. cost of preliminary screening + Medical yoga vs exercise therapy
treatment and material costs in Occupational Health Services setting). Incremental cost –206 –1,519
b
Total societal cost (i.e. total direct cost of intervention and cost of Incremental QALY 0.023 (–0.05; 0.073) 0.023 (–0.05; 0.073)
productivity lost) is from the societal perspective. We refer to minimum ICER (cost per QALY) Cost-effective Cost-effective
earnings per day of SEK 1,145 from Statistics Sweden, equivalent to Cost is in EUR. EQ-5D scores are adjusted for QALYs. ICERs indicated
EUR 132. Totals may not add up to the stated value due to rounding-off cost-effective yield negative incremental cost per individual.
of figures. QALY: quality-adjusted life year; CI: confidence interval.

J Rehabil Med 47
 Cost-effectiveness of medical yoga for low back pain 171

Again, medical yoga cost EUR 206 less than exercise of training. It could also be that it is easier to adhere to medical
therapy. However, the improvement in HRQL did not appear yoga than to exercise intervention.
to be significantly better, which implies that both interventions Cost-effectiveness analysis was performed on all subjects
result in equal improvement in HRQL. Medical yoga has an included in the trial (intention-to-treat analysis), accounting
advantage over exercise therapy as the cost-effective alterna- for the group effect of the intervention. From a societal per-
tive because it is associated with lower cost. spective, medical yoga seemed to be the least costly treatment
compared with both alternatives, exercise therapy and self-care
Societal perspective advice. Thus, medical yoga is more likely to be cost-effective
Considering the intervention cost and production losses to compared with exercise therapy and self-care advice from a
society due to sickness absence, medical yoga costs EUR 1,519 societal perspective. The result also suggests that medical
and EUR 2,124 less per individual, compared with exercise yoga can be a cost-effective treatment from the employer’s
therapy and self-care advice, respectively. Medical yoga will perspective, considering that the increase in the employee’s
be chosen compared with exercise therapy as a cost-effective HRQL can translate into productivity benefits, thus justifying
alternative only in terms of cost. However, medical yoga is the additional resources required for medical yoga treatment
both beneficial with regards to improvement in HRQL and cost implemented within the OHS setting.
compared with self-care advice. As highlighted earlier in the analysis, the incremental cost
If it is assumed that a QALY is worth EUR 11,500, then of medical yoga is much lower than that of exercise therapy
medical yoga could be worthwhile from the societal perspec- and self-care advice from a societal perspective. The observed
tive, with an INB of EUR 1,749 and EUR 2,469 compared cost savings are mainly due to differences in production loss,
with exercise therapy and self-care advice, respectively. The which was lower in the medical yoga group than in the other
positive INB implies that medical yoga can be implemented groups. This implies that the avoided production loss due to
over both interventions with regard to societal willingness to fewer sickness absence days in the medical yoga group bal-
pay for the treatment. This confirms the second hypothesis that anced the cost of implementing the medical yoga. The cost of
medical yoga is more cost-effective than both exercise therapy lost production could either be borne directly by the employer
and self-care advice, from the societal perspective. or by society, depending on, for example, the length of sickness
absence, ability to replace the employee or whether the person
is unemployed. Independently, the impact of production loss
Sensitivity analysis
is highly relevant for decision-makers as presented here in
The cost-effectiveness result, including the estimation of the the economic analysis. The cost of sickness absence used as
multiplier effect on production losses resulting from sickness a proxy measure of lost productivity illustrates the impact of
absence, suggests that the incremental cost is largely sensitive counting the full value of societal costs. Again, it may have
to changes in cost of productivity. The analysis shows that it been relevant also to include the cost of production loss from
will cost EUR 1,887 and EUR 2,761 less per individual to treat an employer perspective. However, in this study we were not
LBP with medical yoga, compared with exercise therapy and able to differentiate the cost of forgone production borne by
self-care advice, respectively. Sensitivity analysis therefore the employer from the overall societal cost. Therefore, no
indicates that medical yoga remains a cost-effective interven- reduction or increase in cost is included from this perspective.
tion compared with exercise therapy and self-care advice. In line with previous studies, we found that yoga therapies
have positive effects for managing physical pain and functional
disabilities related to LBP. The study’s analysis confirms that
Discussion
managing non-specific LBP with medical yoga gives positive
This study shows that medical yoga is associated with greater effects, echoing the conclusions of previous studies (9–11,
health benefits and a greater improvement in HRQL compared 24). This study differs from previous studies, however, in the
with evidence-based self-care advice given by a back pain spe- sense that while previous studies on using yoga therapies for
cialist. The results show that the improvement in HRQL was treating LBP included participants who had chronic LBP, the
not statistically significant for the overall group, but when the participants in this study had non-specific LBP that required
frequency of training days was controlled for participants who early initiation of an intervention. Consequently, this study
trained 2 times or more per week, significant improvement in involved a more prevention-oriented intervention for people
HRQL was found. Thus medical yoga seems to improve HRQL with LBP. This could also explain the modest improvements in
more than self-care advice, but not more than exercise therapy. HRQL after baseline adjustment to the EQ-5D scores.
The results emphasize the importance of adherence to treatment The possibility of medical yoga being cost-effective is
recommendations, in this case training a minimum of 2 times supported by the economic evaluation, as in previous studies
per week, and the relevance of accounting for adherence in (12). Although the estimation of incremental QALY gain was
the analysis when looking at the effects on HRQL. Differences comparable with the findings of previous studies, the study also
between intervention groups are shown in the adherence rate. highlights, in the analysis, the effects of treatment on health if
The differences may imply that motivation of subject in the training recommendations are followed. The incremental costs
interventions groups differed and/or their preference for type of medical yoga intervention compared with exercise therapy

J Rehabil Med 47
172 E. Aboagye et al.

and self-care advice were also considerably lower compared Acknowledgements

with previous studies. The lower costs may be explained by The authors gratefully acknowledge the assistance of FORTE, the Swedish
this study’s use of participants with non-specific LBP. It is research council for health, working life and welfare, for funding the study.
worth mentioning that in previous studies different types of The authors have no conflict of interest to declare.
yoga were used for treating LBP, and that the subjects in those
studies also included chronic LBP patients who may have
required extensive treatments. References
1. Balague F, Mannion AF, Pellise F, Cedraschi C. Non-specific low
Study limitations back pain. Lancet 2012; 379: 482–491.
2. Stanton TR, Latimer J, Maher CG, Hancock M. Definitions of
Although the analyses from a societal perspective included cost recurrence of an episode of low back pain: a systematic review.
of productivity lost to sickness absences, the opportunity costs Spine (Phila Pa 1976) 2009; 34: 316–322.
of time used during the yoga and exercise therapies were not 3. Mody GM, Brooks PM. Improving musculoskeletal health: global
included in the analysis. The rationale was that the opportu- issues. Best Pract Res Clin Rheumatol 2012; 26: 237–249.
4. Ekman M, Jonhagen S, Hunsche E, Jonsson L. Burden of illness
nity costs of the lost productivity were expected to be less for of chronic low back pain in Sweden: a cross-sectional, retrospec-
both yoga and exercise therapy participants because training tive study in primary care setting. Spine (Phila Pa 1976) 2005;
sessions were held on weekday evenings (25). Moreover, par- 30: 1777–1785.
ticipation in this trial was voluntary, with participants (78%) 5. Hayden JA, van Tulder MW, Malmivaara A, Koes BW. Exercise
reporting strong satisfaction with the treatment. This implies therapy for treatment of non-specific low back pain. Cochrane
Database Syst Rev 2005: CD000335.
that participants incurred no appreciable opportunity costs (26). 6. Oesch P, Kool J, Hagen KB, Bachmann S. Effectiveness of exercise
The cost of medication and other private expenses to relieve on work disability in patients with non-acute non-specific low
back pain were not included in the analyses. This could af- back pain: Systematic review and meta-analysis of randomised
fect the cost-effectiveness of the yoga intervention to which controlled trials. J Rehabil Med 2010; 42: 193–205.
7. Rubinstein SM, van Middelkoop M, Kuijpers T, Ostelo R, Verhagen
the study refers. However, the results based on the trial con-
AP, de Boer MR, et al. A systematic review on the effectiveness of
firm outcomes in other studies. Moreover, other health and complementary and alternative medicine for chronic non-specific
non-health benefits for the individual, employer and society low-back pain. Eur Spine J 2010; 19: 1213–1228.
in general (such as reduced healthcare utilization, reduced 8. Schafer LM, Hsu C, Eaves ER, Ritenbaugh C, Turner J, Cherkin
productivity loss of family caregivers, benefits of reduced DC, et al. Complementary and alternative medicine (CAM) pro-
viders’ views of chronic low back pain patients’ expectations of
pain and suffering) may offset these costs over the long term
CAM therapies: a qualitative study. BMC Complement Altern
if treatment benefits of medical yoga are achieved. No side- Med 2012; 12: 234.
effects were reported in all intervention groups with regards 9. Wren AA, Wright MA, Carson JW, Keefe FJ. Yoga for persistent
to treatment outcomes, which should have been considered as pain: new findings and directions for an ancient practice. Pain
costs rather than benefits. 2011; 152: 477–480.
10. Bussing A, Ostermann T, Ludtke R, Michalsen A. Effects of yoga
interventions on pain and pain-associated disability: a meta-
Conclusion analysis. Pain 2012; 13: 1–9.
11. Cramer H, Lauche R, Haller H, Dobos G. A systematic review
This study makes a contribution to research on early interven-
and meta-analysis of yoga for low back pain. Clin J Pain 2013;
tions for non-specific LBP. The study attaches importance to 29: 450–460.
participant adherence to treatment and concludes that an early 12. Chuang LH, Soares MO, Tilbrook H, Cox H, Hewitt CE, Aplin
intervention for LBP using medical yoga can have far-reaching J, et al. A pragmatic multicentered randomized controlled trial of
benefits for employees who show early signs of LBP. The study yoga for chronic low back pain: economic evaluation. Spine (Phila
Pa 1976) 2012; 37: 1593–1601.
also highlights the main determinants of costs to the employer
13. Jensen IB, Bergstrom G, Ljungquist T, Bodin L. A 3-year follow-
and to society associated with treating LBP with medical yoga. up of a multidisciplinary rehabilitation programme for back and
In summary, the result of this economic evaluation supports neck pain. Pain 2005; 115: 273–283.
the use of medical yoga as an early intervention for treating 14. Jensen LD, Maribo T, Schiottz-Christensen B, Madsen FH, Gonge
LBP in an OHS setting. From a decision-making standpoint, B, Christensen M, et al. Counselling low-back-pain patients in
secondary healthcare: a randomised trial addressing experienced
the treatment choice to which a decision-maker can channel workplace barriers and physical activity. Occup Environ Med
resources is medical yoga, which is associated with better 2012; 69: 21–28.
improvement in HRQL and positive incremental net benefits. 15. Linton S, Halldén K. Can we screen for problematic back pain?
The health gains from medical yoga are also cost-efficient A screening questionnaire for predicting outcome in acute and
from the societal perspective, albeit marginally compared with subacute back pain. Clin J Pain 1998; 14: 209–215.
16. Kind P, Brooks R, Rabin R, editors. EQ-5D concepts and methods:
exercise therapy and self-care advice. Based on these results, if A development history. Dordrecht, Netherlands: Springer; 2005.
all 3 interventions are constrained by resources, medical yoga 17. Wittrup-Jensen K, Lauridsen J, Gudex C, Brooks R, Pedersen KM,
treatment is the optimal choice. editors. Estimating Danish EQ-5D tariffs using Time Trade-off

J Rehabil Med 47
 Cost-effectiveness of medical yoga for low back pain 173

(TTO) and Visual Analogue Scale (VAS) method. Proceedings of 22. Soares-Weiser K, Bravo Vergel Y, Beynon S, Dunn G, Barbieri
the 18th Plenary Meeting of the EuroQol Group; 2001. Copenha- M, Duffy S, et al. A systematic review and economic model of the
gen: The EuroQol Group. Available from: http://www.euroqol.org/ clinical effectiveness and cost-effectiveness of interventions for
uploads/media/Proc01Copen20WittrupJensen.pdf. preventing relapse in people with bipolar disorder. Health Technol
18. Drummond M, Sculpher M, Torrance G, O’Brien B, Stoddart G. Assess 2007; 11: iii–iv, ix–206.
Methods for the economic evaluation of health care programmes. 23. Nicholson S, Pauly M, Polsky D, Sharda C, Szrek H, Berger M.
Oxford: Oxford University Press; 2005. Measuring the effects of workloss on productivity with team
19. Manca A, Hawkins N, Sculpher MJ. Estimating mean QALYs in production. Health Econ 2006; 15: 111–123.
trial-based cost-effectiveness analysis: the importance of control- 24. Carter C, Stratton C, Mallory D. Yoga to treat nonspecific low
ling for baseline utility. Health Econ 2005; 14: 487–496. back pain. AAOHN J 2011; 59: 355–361.
20. SCB. Average hourly and monthly earnings of manual and non 25. Olsen J. Principles in health economics and policy. Oxford: Oxford
manual workers Sweden: Statistics Central Bureau, Statistics University Press; 2009.
Sweden; 2012. [Cited 2012/2013; Accessed Apr 2, 2013]. Available 26. Cohen DR, Patel N. The potential to forgo social welfare gains
from: http://www.scb.se/Pages/ProductTables____33516.aspx. through overrelianceon cost effectiveness/cost utility analyses
21. Drummond M, McGuire A. Economic evaluation in health care in the evidence base for public health. J Environ Public Health
merging theory with practice. Oxford: Oxford University Press; 2007. 2009; 2009: 107927.

J Rehabil Med 47