Efficacy and application of Yoga for back pain Loren Fishman, MD

Chronic Pain Perspectives February 2012

Guidelines recommend Yoga for some patients with low back pain. Heres why. Low back pain is one of the most frequent pain complaints of U.S. adults. It is the fifth most common condition for which patients visit their doctor, accounting for approximately 2% of office visits and outpacing routine exams, high blood pressure, and diabetes.1 Among respondents to a 2004 National Institutes of Health Statistics Survey who were asked to report on the four most common types of pain experienced for one day or longer within the previous three months, 27% said low back pain was the most common.2 (Figure) Figure

The cost of diagnosing and treating back pain is high. According to a study in the Journal of the American Medical Association based on an analysis of Medical Expenditure Panel Survey (MEPS) data, in 2005 the mean medical expenditure for respondents with spine problems was $6096 per person, compared to $3516 for respondents without spine problems, for an estimated annual total of $85.9 billion dollars. The largest proportion of this expense was related to outpatient and inpatient services (36% and 28%, respectively), followed by prescription medications (23%).3 The role of Yoga in pain management Joint guidelines by the American College of Physicians and the American Pain Society for the diagnosis and treatment of low back pain recommend that for patients who do not improve on medications, back care information, and selfcare, physicians should consider a number of rehabilitative therapies.4 Among these are exercise therapy, acupuncture, massage therapy, spinal manipulation, cognitive behavioral therapy, and Yoga. In preparing the guidelines, a review of 17 non-pharmacologic therapies for back pain concluded that there was fair evidence for the efficacy of Yoga. A 2002 national survey reported that more than 13 million Americans practice Yoga.5 In 2008, a survey of a representative sampling of 5050 U.S. adults conducted for the Yoga Journal by the Harris Interactive Service Bureau found that 6.9% of U.S. adults, or roughly 15.8 million people, practice Yoga. Data from the survey indicate that almost half (49.4%) of those who practice yoga do so for overall health benefits, and 6.1% practice Yoga on the recommendation of a doctor or therapist.6 (See: A case study from Dr. Fishman) Yoga, a Sanskrit word for to yoke or to join classically referred to a way of joining the individual consciousness with universal consciousness. Believed to have originated from spiritual/meditative traditions in India as long ago as 2600 BCE, it is not a religious practice, but a way of keeping the body fit in its connection to the mind and spirit.7

A case study from Dr. Fishman A 58-year-old lawyer whom Id seen two years ago for a herniated lumbar disc returned with renewed pain. Its higher up in my back this time, she began, fairly grimacing in what most clinicians would call 10/10 pain on the Visual Analogue scale. She said she didnt have any idea how it began, but that it came on suddenly like a lion, and was not going away. I did a standard physical exam. There was no numbness, no particular weakness, and no tingling. Her legs didnt hurt. The lawyer reached her left hand behind her to show me the painful place and indicated a spot that was indeed higher than the previous disc herniation. As she did, an interesting thing happened: the signs of extreme pain on her wellgroomed face essentially disappeared. This was no time to order an MRI or collect blood samples. We had to do something, and now. She couldnt keep her arm behind her like this forever, and without it in that position, the pain was unbearable. In our last encounter, we had alleviated and then cured the pain of her herniated disc through a series of yoga poses that stressed arching the back. During the two years since I saw her last, she had maintained a certain interest in yoga, and practiced it sometimes. I thought we might use her familiarity with yoga to confirm the diagnosis rather than resorting to expensive, time-consuming, and somewhat stressful testing. I asked her to do Ustrasana, the Camel pose, one of the poses that had helped cure her before. As she went into the position, you could feel the tension in the room let go, and watch a calm come over her: first at the shoulders, then in the neck, and finally in her almost incredulous, grateful face. Then, to confirm it still further, I dared touch the spot where lumbar and Y thoracic spines meet, the spot she had indicated to me a few minutes before we started doing yoga. She felt terrific pain when I pressed there, but it vanished almost immediately when she returned to the backbend. Because of the pain coming and going, because of the effect of the mild pressure, I felt quite sure that this patient had a vertebral compression fracture. I taught her a short, symmetrical series of backward arching poses, punctuated with a few abdominal flexion poses that she could do without bending forward, to avoid fatiguing the discs. When the plain X-rays she took after our office visit returned later that evening, they showed a T12 wedge-fracture in bones that appeared like ground glass, a medical code word for osteoporosis. The patient is now doing daily yoga both to relieve her pain and reverse her osteoporosis. Her pain has gone from a 10 to a 2.

In the West, most of the styles taught are based on Hatha Yoga with a focus on physical postures and breathing meant to prepare the practitioner for a mediation practice. Studies indicate that Yoga confers side benefits of improving strength, balance, coordination, range of motion, and reducing anxiety. Instruction in Yoga by a qualified teacher is a low-cost intervention that provides the patient with a series of poses that are memorable and replicable. Once the patient learns them, they become an effective form of self-care and, should the pain recur, afford a way to alleviate it without additional cost. (See: Dr. Fishmans postures for a patient with back pain)

Dr. Fishmans postures for a patient with back pain A nice way to start for a patient with back pain, perhaps someone with a herniated disc, would be with a mild inversion like Viparita Karani, the Legsup-the-wall pose. This is one of a family of fountain of youth poses thought to counter disease. Assuming the patient is in moderate pain, you would move into Salabhasana, or the Locust pose. However, if theyre in terrible pain youd have to go more slowly. In this case youd begin with something between Bhujangasana, the Cobra pose, and the Locust. You would increase it to actually increase the strength of their back muscles by arching the back against gravity, but in a slow and controlled way. Then you might go to yet another back bend, a gradual one like Setu Bandha Sarvangasana, or the Bridge, but not going up too high. You just stretched the back quite a bit so you would want to move into something that would tighten the abdominal muscles for safety. A good choice would be Paripurna Navasana, or the Boat, again supporting them carefully and not letting them go too far even in that pose. Finally, you would go back to something a bit more aggressive, a more dramatically arching back bend such as Ustrasana, the Camel. With this sequence, you might expect the patients back pain to go down by 30% to 40% over several weeks, progressing from the first pose to the second in one week or less, depending on the patient. The best advice I can give any clinician is look and see, feel and pay attention, respond to the actual patient and what is happening to them. Yoga therapy, like medicine itself, is an empirical discipline.

What the studies show Few randomized controlled studies of Yoga for low back pain are found in the literature. Sherman et al conducted the most methodologically rigorous studies providing statistical results to date. In 2005, Sherman and colleagues compared the effects of Yoga with conventional exercises and a self-care book for patients with low back pain.8 A specific sequence of postures was chosen for the Yoga arm of the study. Participants in the exercise arm performed aerobic, strengthening, and stretching exercises. Outcome measures include functional status assessed with the modified Roland Pain Disability Scale; bothersomeness of pain was assessed with an 11-point numeric scale. Participants in the Yoga group had improvements in the disability score that were statistically and clinically significant at 6, 12, and 26 weeks after intervention compared to the self-care book group. All three groups showed reduction in bothersomeness of pain at 12 weeks, but only the Yoga group, continued to exhibit this reduction at 26 weeks. Another study by Sherman et al in 2011 compared Yoga, stretching, and a self-care book. Results of this study showed outcomes for the Yoga group to be superior to the self-care book group at 12 and 26 weeks, but not superior to conventional stretching exercises at either study point in improving symptoms and reducing pain.9 To explore other health benefits of Yoga, a 2010 review of comparison studies was conducted to investigate the hypothesis that potential benefits of Yoga are related to the down-regulation of the hypothalamicpituitaryadrenal axis and the sympathetic nervous system.10 In 12 studies that compared Yoga with exercise, the authors found Yoga to be equal or superior to exercise in nearly all outcomes except physical fitness, and equally or more effective than exercise in outcome measures including heart rate variability, blood glucose, blood lipids, salivary cortisol, and oxidative stress. Few negative effects are found with Yoga compared with other interventions for back pain. However, reports of Yoga injuries do exist. An international survey was conducted to determine the nature, extent, and causes

of Yoga-related injuries.11 Results from the 1,336 respondents (primarily Yoga teachers and Yoga therapists) revealed that injury sites most often mentioned were the lower back, cervical spine, shoulder and rotator cuff, and knee, and were related to specific postures involving these areas. Most Yoga-related injuries were attributed to overzealousness by students, poor technique or alignment, previous injury or condition, and inadequate or improper instruction by teachers. Keys to the prevention of such injuries include the teachers proper understanding of biomechanics when instructing students and awareness of the students level of ability and aggressiveness in attempting the postures. Advice for clinicians Yoga can be effective for seven of the frequent causes of back pain. (See: Brief overview of Dr. Fishmans Yoga for 7 causes of back pain)
Brief overview of Dr. Fishmans Yoga for 7 causes of back pain Yoga may be beneficial for each of these seven known causes of lower back pain Musculoskeletal injury Flat back syndrome Poses that stretch the glutei, the transverses abdominus, the latissimus dorsi will help. Spasm in the quadratus lumborum: forward bends, Balasana, or Child pose and (if possible) Virasana, Hero pose. Herniated disc Yoga extension poses such as Salabhasana or Locust, and Virabhadrasana I, II, and III, also known as the Warrior trilogy, are helpful. Spinal stenosis Yoga flexion poses are helpful. Spondylolisthesis The Yoga pose Vasisthasana, or Side plank, is useful in reconforming the spine. Piriformis syndrome Twisting poses, both standing and seated, are quite effective. Arthritis Different poses work to align and facilitate movement of the various joints. The joints of the cervical, thoracic, and lumbar spine are quite disparate, and require different poses. Sacroiliac joint derangement The Yoga poses Garudasana (Eagle), Bitilasana (Cow), and modified versions of Mayurasana (Peacock), some with the body vertical using a chair, are often curative.

When counseling patients, the clinician can only sensibly talk about what he or she knows. If you think that Yoga can be of value to some of your patients, then learn something about Yoga. Read studies that are randomized, controlled, based on good methodology, and peer reviewed, then advise your patients accordingly. Always advise them to start slowly, and be prepared for an approach to pain management that takes a little time to work. You can learn about Yoga from reading a book, but you cant learn to do Yoga from reading a book alone. Consider giving it a try. You and your patients may be pleasantly surprised at the results.
The author reported no potential conflict of interest relevant to this article. ACKNOWLEDGEMENT: The author wishes to acknowledge Kristen Georgi for her assistance in researching and writing this article.

REFERENCES 1. Deyo RA, Mirza SK, Martin BI. Back pain prevalence and visit rates: estimates from U.S. national surveys, 2002. Spine. 2006;31:2724-2747. 2. National Center for Health Statistics. Health, United States, 2006 with Chartbook on Trends in the Health of Americans. Hyattsville, MD: 2006. 3. Expenditures and health status among adults with back and neck problems. Martin BI, Deyo RA, Mirza SK, et al. JAMA. 2008;299(6):656664. 4. Chou R, Qaseem A, Snow V, et al. Diagnosis and treatment of low back pain: a joint clinical practice guideline from the American College of Physicians and the American Pain Society. Ann Intern Med. 2007 Oct 2;147(7):478-91. 5. Barnes PMBB, Nahin R. Complementary and Alternative Medicine Use Among Adults and Children: United States, 2007. National Health Statistics Report 2008;10:1-23.

6. Yoga Journal Releases 2008, Yoga in America Survey. Available at: http://www.yogajournal.com/press/yoga_in_america. Accessed January 30, 2012. 7. Fishman L, Saltonstall E. Yoga in pain management. In: Integrative pain medicine: The Science and Practice of Complementary and Alternative Medicine in Pain Management. Audette JF, Bailey A, eds. 259-260. Humana Press: Totowa, NJ. 2008. 8. Sherman KJ, Cherkin DC, Erro J, et al. Comparing yoga, exercise, and a self-care book for chronic low back pain. Ann Intern Med. 2005;143(12):849-856. 9. Sherman KJ, Cherkin DC, Wellman RD, et al. A randomized trial comparing yoga, stretching, and a self-care book for chronic low back pain. Arch Intern Med. 2011;171(22):2019-2026. 10. Ross A, Thomas S. The health benefits of yoga and exercise: A review of comparison studies. The Journal of Alternative and Complementary Medicine. 2012;16(1)3-12. 11. Fishman L M, Saltonstall E, Genis S. Understanding and preventing Yoga injuries. International Journal of Yoga Therapy. 2009;18:1-8.