Do Physical Therapy and Yoga Improve Pain and Disability through Psychological Mechanisms? A Causal Mediation Analysis of Adults with Chronic Low Back Pain

J Orthop Sports Phys Ther. 2022 Jul;52(7):470-483. doi: 10.2519/jospt.2022.10813. Epub 2022 May 18.


Objective: To investigate whether indirect effects via psychological mechanisms explain the effects of physical therapy (PT) or yoga versus education on back-related outcomes.

Design: Mediation analyses using data from a randomized controlled trial of PT, yoga, and education interventions for chronic low back pain.

Methods: Primary outcomes were changes in back-related pain on the 11-point numeric rating scale and disability on the modified 23-point Roland-Morris Disability Questionnaire, measured at 52 weeks after randomization. Hypothesized mediators were 12-week changes in pain self-efficacy, fear-avoidance beliefs, depression, anxiety, perceived stress, and sleep quality. We used causal mediation analysis to estimate the total effect, direct effect, indirect effect, and proportion mediated.

Results: We analyzed data from 230 adults (mean age = 46.2 years, 69.6% female, 79.6% non-White). In the PT-versus-education model, when the mediator was perceived stress, the total effect on disability was 2.6 points (95% confidence interval [CI]: 0.3, 4.9) and decomposed into a direct effect of 1.7 points (95% CI: -0.4, 3.8) and an indirect effect 0.9 points (95% CI: 0.1, 2.0; proportion mediated, 34%). No other psychological construct was a significant mediator.

Conclusion: Improvements in perceived stress mediated improvements in disability after PT treatment compared to education. Other psychological outcomes did not mediate the effect of yoga or PT on pain or disability outcomes compared to education. J Orthop Sports Phys Ther 2022;52(7):470-483. Epub: 18 May 2022. doi:10.2519/jospt.2022.10813.

Trial registration: NCT01343927.

Keywords: biopsychosocial; chronic pain; mechanism; mediation; physical therapy; yoga.

Publication types

  • Randomized Controlled Trial
  • Research Support, N.I.H., Extramural

MeSH terms

  • Adult
  • Chronic Pain* / therapy
  • Female
  • Humans
  • Low Back Pain* / psychology
  • Low Back Pain* / therapy
  • Male
  • Mediation Analysis
  • Middle Aged
  • Physical Therapy Modalities
  • Treatment Outcome
  • Yoga*

Associated data