Complementary Therapies in Medicine 79 (2023) 102996

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Complementary Therapies in Medicine

journal homepage: www.elsevier.com/locate/ctim

Pain reduction, physical performance, and psychological status compared

between Hatha yoga and stretching exercise to treat sedentary office
workers with mild/moderate neck/shoulder pain: A randomized controlled
non-inferiority trial☆
V. Kuptniratsaikul a, *, C. Muaksorn b, C. Koedwan b, O. Suesuwan c, A. Srisomnuek d
a
Department of Rehabilitation Medicine, Faculty of Medicine Siriraj Hospital, Mahidol University, Bangkok, Thailand
b
Division of Physical Therapy, Department of Rehabilitation Medicine, Faculty of Medicine Siriraj Hospital, Mahidol University, Bangkok, Thailand
c
Division of Surgical Nursing, Department of Nursing, Siriraj Hospital, Bangkok, Thailand
d
Research Group and Research Network Division, Research Department, Faculty of Medicine Siriraj Hospital, Mahidol University, Bangkok, Thailand

A R T I C L E I N F O A B S T R A C T

Keywords: Objective: To investigate pain reduction, physical performance, and psychological status compared between
Pain reduction Hatha yoga and stretching exercises.
Physical performance Design: Randomized controlled non-inferiority trial
Psychological status
Subjects: 150 sedentary office workers with mild/moderate neck/shoulder pain.
Hatha yoga
Stretching exercise
Interventions: Participants received group Hatha yoga or stretching exercise once a week (30 min for 4 weeks),
Sedentary office workers and were asked to practice at home. Subjects were followed up at 4 and 8 weeks.
Main outcome measures: The primary outcome was a numeric rating scale (NRS) score. The secondary outcomes
were a sit-and-reach test, Functional Reach Test, Neck Disability Index, pain pressure threshold, Patient Health
Questionnaire-9, General Anxiety Disorder-7, and the EuroQoL.
Results: Of the 150 subjects, 59 and 71 participants in the Hatha yoga and stretching groups were analyzed. At
baseline, no significant differences between groups were found. After 4 weeks, the mean difference in the NRS
score was statistically significant between groups (p < 0.001), including a 95% confidence level of < 1 score, but
there was no significant difference between groups for any other outcome. Most participants reported being
satisfied with their assigned treatment (98.3–100%), and rated themselves as improved or much improved
(91.8–98.3%) (both p > 0.05 between groups). The most common adverse events were musculoskeletal pain and
muscle tension. Repeated measures analysis of variance that compared among weeks 0, 4, and 8 revealed no
significant difference between groups.
Conclusion: Hatha yoga was tentatively found to be non-inferior to stretching exercise relative to safety, for
decreasing pain, anxiety, and depression, and for improving flexibility, neck functions, and quality of life.

1. Introduction of this change is that it has resulted in a progressively sedentary lifestyle

for many affected people.1 It was reported that 50% of office workers
Advancements in technology have exerted profound changes in how suffer from moderate musculoskeletal (MSK) pain, and 30% of those
we live and work. Many jobs are now heavily dependent on computer- develop severe back and neck pain.2,3 Moreover, anxiety and depression
related work, and this often requires lengthy periods of working on are major psychological problems that are prevalent in patients with
the computer, whether at home or at the office. The less favorable aspect chronic neck pain.4 The other consequent burden is employee

Clinical Trials Registration: This study was also registered with the Thai Clinical Trials Registry (reg. no. 20200605006).
☆

* Correspondence to: Department of Rehabilitation Medicine, Faculty of Medicine Siriraj Hospital, Mahidol University, 2 Wanglang Road, Bangkoknoi, Bangkok
10700, Thailand.
E-mail addresses: [email protected] (V. Kuptniratsaikul), [email protected] (C. Muaksorn), [email protected] (C. Koedwan), oaytip.
[email protected] (O. Suesuwan), [email protected] (A. Srisomnuek).

https://doi.org/10.1016/j.ctim.2023.102996
Received 24 January 2023; Received in revised form 11 October 2023; Accepted 17 October 2023
Available online 19 October 2023
0965-2299/© 2023 The Authors. Published by Elsevier Ltd. This is an open access article under the CC BY-NC-ND license (http://creativecommons.org/licenses/by-
nc-nd/4.0/).
V. Kuptniratsaikul et al. Complementary Therapies in Medicine 79 (2023) 102996

absenteeism. Data from a European research group reported that 43% of with a history of surgery or severe trauma at the neck or shoulder were
all employees were absent from work at least 1 day within the last year, excluded. After screening, participants were asked to provide socio­
and 23% were absent from work more than 5 days due to work-related demographic data. Study subjects were then queried regarding their
MSK problems.5 Dieleman et al. reported the estimated money spent on pain score during work and its effect on their work, their leisure time,
personal health care in the United States from 1996 to 2013. Low back their physical performance, and their psychological status (baseline
and neck pain accounted for the third-highest amount with an estimated assessment). The level of pain was assessed using NRS scoring, which
healthcare outlay of $87.6 billion.6 ranges from 0 to 10.20 A higher score indicates a greater degree of pain
To prevent office syndrome, physical activity, and ergonomics and vice versa. The pain pressure threshold was measured according to
should be encouraged. Many interventions have been proposed to treat the affected muscle’s sensitivity to pressure using a digital algometer
pain in the neck and shoulders, including therapeutic ultrasound7, (model FDX-25; Wagner Instruments, Greenwich, CT, USA). Briefly, a
transcutaneous electrical nerve stimulation (TENS)8, shockwave9, and researcher applied pressure at the location of maximal tenderness at the
stretching exercise.10 To achieve optimal outcomes, the aforementioned affected muscle with a pressure of 5 newtons per second until the
interventions should be combined with the simultaneous implementa­ participant started to feel pain.21
tion of ergonomic changes to help heal and prevent soft tissue and MSK Physical performance was evaluated using 2 assessment tools. The
injuries in office-type work environments. This strategy will help to evaluator let all participants perform and practice each physical per­
maximize productivity and improve worker safety in the office formance test before starting the test. 1) Back flexibility was measured
workplace. using the sit-and-reach test.22 Participants were positioned in a long
In daily practice of rehabilitation doctors, stretching exercise is one sitting position with the ankles at 90-degree flexion, after which they
of our intervention, frequently prescribed for pain relief and muscle were asked to reach forward as far as possible. The distance achieved by
relaxation. In 2016, Tunwattanapong et al. performed a randomized the patient when attempting to touch his/her toes was considered zero,
controlled trial of stretching exercise 3 times a week for 4 weeks and and a demonstrated inability to touch the toes was recorded as a nega­
found that it can reduce neck pain and improve functions and quality of tive number. 2) The Functional Reach Test was used to evaluate bal­
life in office workers.10 In addition, Shariat and colleagues showed that ance.23 Participants were positioned upright standing perpendicular to a
stretching exercises can significantly improve neck pain among office wall. They were then asked to reach as far forward as they could without
workers aged 20–50 years old with neck pain.11 Moreover, stretching losing their balance. The distance reached by the tip of the middle finger
exercise is cost-effective compared to medical advice to stay active. It of the dominant side was recorded. Both of the aforementioned tests
also revealed with higher QALY gain than massage and combined ex­ were performed twice with a 1-minute rest in between, and the better of
ercise and massage.12 Stretching exercise can be recommended as the two scores for each test was recorded.
appropriate therapy to relieve pain due to its low cost.13 The Neck Disability Index (NDI) questionnaire was used to evaluate
Hatha yoga is a kind of practice that a beginner can practice, and neck function.24 This questionnaire consists of 10 items, including pain,
Hatha yoga was reported to increase relaxation.14 Hatha yoga is a form self-care, lifting, reading, headache, concentration, workability, car
of alternative medicine that focuses on both mind and body to promote driving, sleeping ability, and recreational activity. Each item is rated
physical and mental wellness. Hatha yoga focuses on relaxation (shava using a six-point Likert scale with a higher score indicating a higher level
asana), physical postures (asana), breathing regulation techniques of disability. The Thai version of the NDI questionnaire demonstrated
(pranayama), and meditation (dhyana)15, and it can improve many as­ good psychometric properties.25
pects of the body and mind, including flexibility, focus, mindfulness, and Psychological status was evaluated using the following 3 different
relaxation. Previously reported effects of Hatha yoga include decreased questionnaires. 1) The Patient Health Questionnaire – 9 (PHQ-9) is a 9-
stress16, increased relaxation17, and decreased anxiety18 and depres­ item questionnaire that is used to evaluate depression.26 The score
sion.19 Nowadays there is currently a scarcity of data specific to the ranges from 0 to 27, and the cut point that indicates the presence of
efficacy of Hatha yoga as a therapeutic modality in sedentary office depression is ≥ 9. 2) The General Anxiety Disorder - 7 (GAD-7) is a
workers. Accordingly, the aim of this randomized controlled 7-item questionnaire that is used to evaluate anxiety.27 The score ranges
non-inferiority study was to investigate pain reduction, physical per­ from 0 to 21, and a score ≥ 10 indicates the presence of anxiety. 3) The
formance, and psychological status compared between Hatha yoga and Thai version of the EuroQoL Five Dimension Five Level (EQ-5D-5 L)
stretching exercise among sedentary office workers with mild/moderate questionnaire was used to assess quality of life.28 The five dimensions
MSK pain of the neck/shoulders. If Hatha yoga is found to alleviate pain, include mobility, self-care, usual activities, pain/discomfort, and anx­
decrease muscle stiffness, and improve quality of life, it can be consid­ iety/depression. Each dimension is rated, as follows: no problems (level
ered an alternative or adjunct to stretching exercise for the therapeutic 1), slight problems (level 2), moderate problems (level 3), severe
treatment of sedentary office workers with mild to moderate MSK pain. problems (level 4), and unable to perform (level 5).
After completing the baseline assessment, participants were allo­
2. Method cated into 1 of 2 groups using a computerized random number tech­
nique. The random allocation sequence was concealed in a sealed
This prospective study was conducted in an outpatient setting at the envelope by a research nurse who was not involved in the patient
Department of Rehabilitation Medicine of the Faculty of Medicine Siriraj evaluation process. A physical therapist (RY) then assigned each patient
Hospital, Mahidol University, Bangkok, Thailand from September 2020 to the intervention listed in the envelope. Subjects in the study group
to July 2022. The study protocol was in accordance with the principles were taught Hatha yoga in a group by a trained nurse who has 20 years
set forth in the 1964 Declaration of Helsinki, and was approved by the of experience teaching Hatha yoga. Participants attended group Hatha
Institutional Review Board of Siriraj Hospital (approval no. 432/2020). yoga in the gym of our physical therapy unit every Wednesday after­
All study participants provided written informed consent to participate. noon. During Hatha yoga sessions, the gym was air-conditioned and the
This study was also registered in the Thai Clinical Trials Registry (reg. temperature was set at 25 degrees Celsius. There was one Hatha yoga
no. 20200605006). session per week (30 min) for four weeks for a total of 4 sessions. Sub­
The inclusion criteria for this study were 1) office worker aged 30–50 jects in the control group received group muscle stretching exercise
years having MSK pain at the neck and shoulder area with a numeric training. The muscles and muscle groups focused upon were at the neck,
rating scale (NRS) score of ≥ 3/10 for at least 3 months (the authors did the shoulders, the trunk, the knee flexor, and the ankle plantar flexor.
not collect data specific to the exact duration of pain); 2) ability to Similar to the study group, the control group received training in an air
communicate in Thai language; and, 3) expressed willingness and condition room for 30 min one time per week for 4 weeks (4 sessions).
intention to cooperate with and complete the study. Interested subjects Control group participants were taught by a licensed physical therapist

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V. Kuptniratsaikul et al. Complementary Therapies in Medicine 79 (2023) 102996

Fig. 1. Flow diagram of the study protocol. (Abbreviation: NRS, numeric rating scale).

with more than 15 years of professional work experience. Pictures

Table 1
concerning the details specific to both regimens are presented in the
Baseline characteristics compared between the stretching and Hatha yoga
supplement files.
groups.
Participants received a brochure with details specific to Hatha Yoga
Characteristics Stretching Hatha p- or stretching exercises as they were grouped. During weekdays, they
(n = 75) yoga value
(n = 75)
were asked to perform additional practice at home as they were taught
in group sessions, for a 30-minute session every day, and recorded the
Age (years), mean±SD 38.1 ± 6.5 38.9 0.476
frequency of home practice only the day they practiced at home by
± 7.9
Female gender, n (%) 66 (88.0%) 61 0.257 themselves in their logbook.
(81.3%) They had to join the class group weekly for 4 weeks, their attendance
2
Body mass index (kg/m ), mean±SD 23.9 ± 4.2 24.5 0.418 was recorded by the therapist. If participants had questions, they could
± 4.8 ask from the trainer that led the weekly group session. Study subjects
Work experience (years), mean±SD 12.1 ± 6.6 12.6 0.616
± 6.6
were also invited to contact the researchers via telephone if they had a
Duration of computer use per day 7.6 ± 1.5 7.4 ± 1.3 0.318 need to do so.
(hours), mean±SD The exercise adherence was evaluated and recorded by a study nurse
Sick leave days due to neck pain (days), 1.7 ± 1.2 2.3 ± 2.1 0.333 during the follow-up period. The adherence data that were recorded
mean±SD
included both the number of weekly sessions attended at the hospital
A p-value< 0.05 indicates statistical significance and the number of practice sessions conducted at home. Good adherence
Abbreviation: SD, standard deviation

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V. Kuptniratsaikul et al. Complementary Therapies in Medicine 79 (2023) 102996

Table 2
Primary and secondary outcomes compared between weeks 0 and 4, and the mean difference at week 4 between the stretching and Hatha yoga groups (per protocol
analysis).
Parameters Stretching group (n = 73) Hatha yoga group (n = 60) Mean difference# p
(95%CI)
Week 0 Week 4 p Week 0 Week 4 p

PHYSICAL
NRS (0–10) 6.60 ± 1.45 3.42 ± 2.14 < 0.001 6.53 ± 1.69 3.13 ± 2.07 < 0.001 0.26 (− 0.42, 0.94) < 0.001 *
Sit-and-reach test -5.26 ± 8.86 0.18 ± 8.31 < 0.001 -3.26 ± 8.35 2.89 ± 7.20 < 0.001 -1.19 (− 2.70, 0.31) 0.119
Pain pressure threshold 2.27 ± 0.83 2.63 ± 0.82 < 0.001 2.27 ± 0.81 2.74 ± 0.74 < 0.001 -0.11 (− 0.34, 0.12) 0.345
Functional reach test 36.21 ± 4.60 39.85 ± 3.63 < 0.001 36.58 ± 5.36 40.01 ± 4.33 < 0.001 0.01 (− 1.13, 1.14) 0.991
Neck Disability Index 23.80 ± 12.10 10.68 ± 7.58 < 0.001 22.63 ± 10.01 10.20 ± 6.30 < 0.001 0.14 (− 2.01, 2.28) 0.901
PSYCHOLOGICAL
GAD-7 2 (0, 4) 0 (0, 2) < 0.001 2 (0, 3) 1 (0, 2) 0.010 - 0.198
PHQ-9 3 (1, 6) 0 (0, 3) < 0.001 3.5 (1.3, 6.0) 1 (0, 3) < 0.001 - 0.420
QUALITY OF LIFE
EQ-5D-5 L 0.8540 ± 0.1204 0.9566 ± 0.0558 < 0.001 0.8638 ± 0.1088 0.9495 ± 0.0469 < 0.001 0.0090 (− 0.0072, 0.0252) 0.273

Data presented as mean plus/minus standard deviation or median and interquartile range
A p-value of less than 0.05 for the comparison between week 0 and week 4 indicates statistical significance
*A one-sided p-value < 0.025 indicates statistical significance for non-inferiority test
#
Mean difference between study and controls at week 8 adjusted using analysis of covariance (ANCOVA)
Abbreviations: CI, confidence interval; EQ-5D-5 L, EuroQol 5 Dimensions 5 Levels; GAD-7, General Anxiety Disorder-7; NRS, numeric rating scale; PHQ-9, Patient
Health Questionnaire-9

physical therapy or participate in other types of exercise during the

Table 3 study. Any new events that occurred during the study were recorded as
Patient satisfaction and patient global assessment at week 4 compared between adverse events in the study participant’s logbook.
groups. The primary and secondary outcomes were reevaluated at the end of
Assessment parameter Stretching Hatha yoga p- the study (4 weeks; second assessment), and then again at 1 month after
group group value the end of the study (follow-up period; third assessment) by a blinded
(n = 73) (n = 60) assessor who was not involved in the group randomization process.
Patient satisfaction, n (%) 0.620 At the end of the study, participants were asked to evaluate their
Very satisfied 61 (83.6%) 51 (85.0%) satisfaction with their assigned regimen (Likert scale: very satisfied,
Satisfied 12 (16.4%) 8 (13.3%)
satisfied, or unsatisfied), and to provide a global assessment of the ef­
Unsatisfied 0 (0.0%) 1 (1.7%)
Patient global assessment, n 0.066 ficacy of the assigned intervention (Likert scale: much improved,
(%) improved, no observable change, or not improved). All participants that
- Much improved 37 (50.7%) 24 (40.0%) were still in the study at the 4-week time point were invited for follow-
- Improved 30 (41.1%) 35 (58.3%) up at one month after the end of the study (at 8 weeks) to reevaluate
- No observable change 6 (8.2%) 1 (1.7%)
their pain score, physical performance, and psychological status.
A p-value< 0.05 indicates statistical significance
2.1. Sample size calculation and statistical analysis
Table 4
To calculate the sample size for this study, we used the standard
Adverse events of practice at week 4 compared between the stretching and
Hatha yoga groups. deviation (SD) of the pain score from previously published studies by
Tunwattanapong, et al.10 and Sharan, et al.29 The sample size was
Adverse events* Stretching Hatha yoga p-
estimated to test the non-inferiority of Hatha yoga to stretching exercise
(n = 72), n (n = 60), n value
(%) (%) relative to the change in NRS-pain score. Using the nQuery program
(GraphPad Software, Boston, MA, USA), a prespecified margin for
Number of patients with at least one 11 (15.3%) 10 (16.7%) 0.828
adverse event non-inferiority trial of 1.030, 90% power to detect non-inferiority with a
Number of events one-sided significance level of 2.5%, and a standard deviation of 1.8, our
Severe pain 1 (1.4%) 1 (1.7%) 1.000 calculation yielded a minimum of 57 participants per group. Since this
Numbness - - study was performed during the COVID-19 pandemic, an estimated
Weakness - -
unusually high 25% drop-out rate was expected, so the sample size was
Falling - -
Joint swelling - - increased to 75 participants per group.
Fainting - - Concerning statistical analysis, patient characteristics are summa­
Musculoskeletal pain 8 (11.1%) 3 (5.0%) 0.206 rized using descriptive statistics. Kolmogorov-Smirnov test was used to
Muscle tension 2 (2.8%) 3 (5.0%) 0.659
evaluate the normality of continuous data. Mean ± SD is reported for
Vertigo 0 (0.0%) 1 (1.7%) 0.455
Dyspepsia 0 (0.0%) 2 (3.3%) 0.205 normally distributed data, and median and interquartile range (IQR) is
reported for non-normally distributed data. Unpaired t-test and Mann-
A p-value< 0.05 indicates statistical significance
Whitney U test were used to compare continuous data with normal
*Adverse events included all events that occurred after recruitment, including
and non-normal distribution, respectively. Categorical data are reported
those that occurred among patients who had to withdraw from the study due to
as number and percentage, and chi-square test was used to compare
adverse events
categorical data. For the primary outcome (i.e., NRS), non-inferiority
was accepted if the lower bound of the two-sided 95%confidence in­
was defined as having performed at least 16 sessions (group sessions +
terval (95%CI) for the difference in the mean NRS between groups
home sessions). A total number of practice sessions of less than 16 was
(stretching group and Hatha yoga group) was less than the non-
regarded as poor adherence.
inferiority margin of 1.0. The differences between pre- and post-
To prevent co-intervention, participants were asked not to receive
treatment within group were analysed using paired t-test and

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Table 5
Adherence compared between the control and study groups at week 4 and week 8.
Adherence Week 4 p Week 8 p

Stretching Hatha yoga Stretching Hatha yoga

(n = 73), n (%) (n = 60), n (%) (n = 71), n (%) (n = 59), n (%)

Good (≥16/20) 25 (34.2%) 27 (45.0%) 0.210 12 (16.9%) 11 (18.6%) 0.964

Fair (12–15) 30 (41.1%) 16 (26.7%) 25 (35.2%) 20 (33.9%)
Poor (<12) 18 (24.7%) 17 (28.3%) 34 (47.9%) 28 (47.5%)

Fig. 2. The numeric rating scale (2 A), and pain pressure threshold (2B) compared among weeks 0, 4, and 8, and between the stretching and Hatha yoga groups.

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V. Kuptniratsaikul et al. Complementary Therapies in Medicine 79 (2023) 102996

Fig. 3. The sit-and-reach test (3 A), and Functional Reach Test (3B) compared among weeks 0, 4, and 8, and between the stretching and Hatha yoga groups.

Wilcoxon signed-rank test. Mean differences in outcomes with normally sided p-value of less than 0.05 was considered statistically significant
distributed data at the end of four weeks adjusted from baseline between for the non-inferiority test and the equality test, respectively. All data
treatment groups were calculated using analysis of covariance were analyzed using PASW Statistics (SPSS) version 18.0 (SPSS, Inc.,
(ANCOVA). Differences in outcomes with non-normally distributed be­ Chicago, IL, USA).
tween treatment groups were compared using Mann-Whitney U test.
Changes in outcomes over time among the week 0, week 4, and week 8 3. Results
time points were analyzed using repeated measures analysis of variance
(ANOVA) and Friedman test. Patient satisfaction, patient global assess­ Of the 162 patients that were assessed for eligibility, 150 were
ment, and the adherence were compared between groups using chi- recruited and randomized to the study or control groups (75 to each
square test. The proportions of adverse events were compared using group). At week 4, there were 15 and 2 participants from the Hatha yoga
Fisher’s exact test. A one-sided p-value of less than 0.025, and a two- and stretching exercise groups, respectively, that were lost to follow-up.

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V. Kuptniratsaikul et al. Complementary Therapies in Medicine 79 (2023) 102996

Fig. 4. The Neck Disability Index (NDI) compared among weeks 0, 4, and 8, and between the stretching and Hatha yoga groups.

An additional 1 and 2 participants from the Hatha yoga and stretching 4. Discussion
exercise groups, respectively, were lost to follow-up at week 8. The
remaining 59 subjects from the Hatha yoga group and 71 participants This study aimed to evaluate the effect of Hatha yoga compared to
from the stretching exercise group were included in the final analysis. stretching exercise for treating mild/moderate neck and/or shoulder
The reasons for loss-to-follow-up are reported in Fig. 1. pain in sedentary office workers. After 4 once-a-week sessions of each
The baseline sociodemographic characteristics of study participants group, the adjusted mean difference in the primary outcome (NRS) be­
are shown in Table 1. There was no significant difference between tween groups was 0.26 (95%CI: − 0.42, 0.94), which was less than the
groups for any of the 6 factors, including age, gender, body mass index prespecified pain score margin (<1.0) that we hypothesized would
(BMI), years of work experience, duration of computer use per day, and indicate non-inferiority. In addition, the p-value for the between groups
the number of sick leave days taken due to neck pain. The primary and comparison was analyzed by non-inferiority test, and a p-value < 0.025
secondary outcomes compared between weeks 0 and 4, and the mean indicates statistically significant for non-inferiority. These results
difference at week 4 between the stretching and Hatha yoga groups strongly suggested that Hatha yoga was non-inferior to stretching ex­
using per-protocol analysis are presented in Table 2. The primary ercise for pain relief in sedentary office workers with mild/moderate
outcome (NRS) showed significant improvement compared to baseline neck/shoulder pain. When compared to baseline, the other evaluated
data in both groups. When compared between groups, the primary outcomes in both groups showed significant improvement; however, no
outcome (NRS) was statistically significantly different (p < 0.001) with significant difference between groups for any of these outcomes was
a mean difference and 95%CI of less than 1 score. All of the secondary found, including sit-and-reach test, Functional Reach Test; pain pressure
outcomes, including the physical and psychological outcomes, showed threshold, and Neck Disability Index. These findings demonstrate that
significant improvement compared to baseline in both groups; however, both Hatha yoga and stretching exercise can decrease pain, improve
no statistically significant differences between groups were found for flexibility and balance abilities, increase muscle tolerance to pressure,
any of the secondary outcomes. and improve neck function.
Patient satisfaction and global assessment evaluated at week 4 Hatha yoga and stretching exercise are two different practices with
showed no significant differences between groups (Table 3). The most distinct differences in the mechanisms and outcomes. While stretching
common adverse events were MSK pain and muscle tension with no exercises are focused on increasing flexibility, Hatha yoga is a training
significant differences between groups (Table 4). Concerning adherence regimen for the mind, body, and soul.31 The observed ability of Hatha
with the protocols, the frequency showed no significant difference be­ yoga to reduce pain can be attributed to the fact that Hatha yoga im­
tween groups at both week 4 and week 8; however, the assigned practice proves flexibility, loosens muscles, and alleviates pain via various yoga
regimen was performed less frequently at week 8 compared to week 4 in techniques, including but not limited to relaxation, physical postures,
both groups (Table 5). breath control, and meditation. Yoga also promotes energy balance,
The primary and secondary outcomes compared among weeks 0, 4, lowered breathing and heart rate, decreased cortisol levels, and
and 8, and between the stretching and Hatha yoga groups using repeated enhanced blood circulation.15 However, there was a different attrition
measures ANOVA are shown in Figs. 2–6. The results showed among groups. The reasons Hatha yoga can alleviate pain through
improvement in all outcomes compared to baseline; however, there was stretching exercises may come from participants in the Hatha yoga
no significant difference between groups for any evaluated parameter group having more work experience and sick leave days from neck pain
(Figs. 2A, 2B – NRS: p = 0.144, pain pressure threshold: p = 0.613) than the stretching group. This may cause them to participate in Hatha
(Figs. 3A, 3B - sit-and-reach test: p = 0.125, Functional Reach Test: yoga (adherence) more frequently than the stretching exercise group.
p = 0.884) (Fig. 4 - Neck Disability Index: p = 0.469) (Figs. 5A, 5B - The findings of our study are similar to those reported by Li, et al.
GAD-7: p > 0.05, PHQ-9: p > 0.05) (Fig. 6 - EQ-5D-5 L: p = 0.762). who conducted a meta-analysis of the effect of Hatha yoga on patients

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V. Kuptniratsaikul et al. Complementary Therapies in Medicine 79 (2023) 102996

Fig. 5. The General Anxiety Disorder – 7 (5 A), and Patient Health Questionnaire – 9 (5B) compared among weeks 0, 4, and 8, and between the stretching and Hatha
yoga groups.

with chronic nonspecific neck pain.32 They concluded that Hatha yoga uncontrolled pilot study among 8 physiotherapists investigated the ef­
can relieve neck pain intensity, improve neck function, increase range of fect of Hatha yoga on chronic neck pain originating from the upper
motion (ROM), and improve patient quality of life and mood. Another trapezius muscle.29 Study subjects performed a structured Hatha yoga
meta-analysis study of 7 randomized control trials that investigated the protocol 5 days per week for 4 weeks, and all outcomes significantly
effects of Thai Hatha yoga training on physical fitness found that Hatha improved after intervention, including Disability of Arm, Shoulder and
yoga can significantly improve body flexibility after 4 weeks (3.9 cm, Hands (DASH) score, Neck Disability Index (NDI), Visual Analogue Scale
95%CI: 3.9–4.0; p < 0.001) and after 8 weeks (8.9 cm, 95%CI: 7.4–10.5; (VAS), Pressure Pain Threshold (PPT) for Trigger Points, Cervical Range
p < 0.001) compared to the control group.33 They also found that reg­ of Motion (CROM), and both grip and pinch strength. Other study per­
ular practice using Thai Hatha yoga can increase flexibility. An formed by Bakken et al. to investigate the effect of 4-session of spinal

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V. Kuptniratsaikul et al. Complementary Therapies in Medicine 79 (2023) 102996

Fig. 6. The EuroQol 5 Dimensions 5 Levels (EQ-5D-5 L) compared among weeks 0, 4, and 8, and between the stretching and Hatha yoga groups.

manipulation therapy with home stretching exercise for 2 weeks in pa­ 3). Therefore, if office workers maintain the same work routine and
tients with persistent or recurrent neck pain. They found no differences activities, but reduce or discontinue their exercise, there is a high
between groups for any of the heart rate variability.34 probability of MSK pain recurrence. Accordingly, these patients should
The results of our study also showed a significant reduction in both be counseled regarding the importance of both continuing to participate
anxiety and depression in both groups. These symptoms were reported and to pursue ergonomic changes that will lessen the likelihood of MSK
to be associated with chronic MSK pain.35 Mehta and Sharma conducted pain recurrence.
a systematic review of 18 studies that investigated the effect of Hatha
yoga on depression, and they reported Hatha yoga to be beneficial as a 4.1. Strengths and limitations
complementary therapy for depression and depressive symptoms.36
Other systematic reviews also found Hatha yoga to be effective for This study has some important strengths. First, our study’s ran­
reducing depression.14, 18,37 Concerning the effect of Hatha yoga on domized controlled non-inferiority design facilitated our ability to
anxiety, a 2018 meta-analysis by Vollbehr, et al. found that Hatha yoga conclusively determine that Hatha yoga is non-inferior to stretching
had no significant effect on anxiety disorders compared to standard exercise in this patient population. Second, although we did experience
treatment or active control groups. However, Hatha yoga was reported some subject dropouts during the full 8-week duration of the study, we
to exert a more positive effect on depression compared to were able to initially recruit the minimum number of subjects that were
psychoeducation.38 prescribed by our sample size calculation. Third, our primary and sec­
Regarding patient quality of life, we found a significant increase in ondary outcomes painted a holistic picture of the patient’s experience,
quality of life from baseline to 4 weeks in both study groups. Moreover, including pain reduction, physical performance, psychological status,
the vast majority of participants reported being satisfied with their and quality of life. Fourth and last, all assessments were performed by an
assigned regimen (98.3–100%), and most rated themselves as improved assessor who was blinded to the assigned regimen.
or much improved (91.8–98.3%) at the end of the study. Concerning Our study also has some mentionable limitations. First, subjects in
adverse events, only MSK pain and muscle tension were reported. The both groups were only given one 30-minute session once a week for 4
number of affected study subjects was small, the symptoms were mild, weeks due to the heavy workload of the instructors. To compensate for
and all adverse events were resolved within a few days in all cases. These this, we provided an instruction brochure and advised subjects to
findings indicate both Hatha yoga and stretching exercise to be safe and perform their regimen at home during the week; however, the adher­
effective regimens for treating sedentary office workers with mild/ ence was lower than hoped and anticipated, especially during the
moderate MSK pain. follow-up period. We advised participants to perform assigned practice
Concerning the adherence during weeks 4–8, participants in both during weekdays by giving them a brochure, but it’s still low adherence,
groups performed activities less frequently at week 8 compared to week especially during the follow-up period. Second, several subjects were
4. The authors did not follow-up weekly due to the short 4-week dura­ lost to follow-up during the course of the study. One possible explana­
tion of the study. The authors provided subjects in both group program tion is that some participants found the yoga hard to follow or didn’t like
at home. This brochure was used to motivate and remind participants it, and therefore refused contact or to be assessed, leaving only the
about home exercise, which was an adjunct to the 4 weekly group participants who liked yoga and found it helpful to be followed up.
practice sessions at the hospital. In addition, the authors reminded all Third, the number of dropouts was much larger in the Hatha yoga group
participants to perform practice every weekday similar to how they did than in the exercise group. If the outcomes for the Hatha yoga partici­
during first 4 weeks. A possible explanation for the reduced frequency of pants who were lost to follow-up were systematically different from the
exercise during the 4-week follow-up period may be the reduced mean outcomes for those who remained in the study (e.g., yoga was helpful for
pain score from baseline to the 4-week time point (decreased from 6 to participants who were followed up while yoga was not helpful for

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V. Kuptniratsaikul et al. Complementary Therapies in Medicine 79 (2023) 102996

participants who refused follow-up), the effect estimate would be biased 4 Elbinoune I, Amine B, Shyen S, Gueddari S, Abouqal R, Hajjaj-Hassouni N. Chronic
neck pain and anxiety-depression: prevalence and associated risk factors. Pan Afr
and the benefits observed in the Hatha yoga group would not be
Med J. 2016;24:89. https://doi.org/10.11604/pamj.2016.24.89.8831.
representative of the outcomes for the Hatha yoga group as a whole. 5 Coffeng JK, Hendriksen IJ, Duijts SF, Twisk JW, van Mechelen W, Boot CR.
Fourth, to calculate the sample size, we used the difference of pain score Effectiveness of a combined social and physical environmental intervention on
of 1.0 with SD of 1.8 to make the effect size 0.56, which is larger than the presenteeism, absenteeism, work performance, and work engagement in office
employees. J Occup Environ Med. 2014;56:258–265. https://doi.org/10.1097/
margin used in most studies. Therefore, readers should interpret the JOM.0000000000000116.
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office workers with mild to moderate pain intensity, so our findings may health, 1996-2013. JAMA. 2016;316(24):2627–2646. https://doi.org/10.1001/
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