Yoga for Back Pain

Back pain is a ubiquitous problem that is too frequently mistreated, leading to distress, disability, and economic burdens on individuals and societies. The most prevalent type is non-specific chronic low back pain (also called lower back pain), which does not have a specific cause such as an injury or disease. Programmes of yoga for back pain are common, but yoga therapy may be preferable to general yoga classes because yoga therapists can offer deeper knowledge and skill in individualisation. While general yoga classes could help to promote healing, specialised education in back pain is necessary for yoga professionals because, as with any physical activity, yoga also has the potential to worsen back pain if approached incorrectly. Back pain is one of the many conditions targeted in The Minded Institute’s yoga therapy training course.

Yoga Therapy and Low Back Pain

Chronic low back pain (LBP) reduces quality of life, accompanies many comorbidities, and raises mortality risks associated with lack of physical activity and with cardiovascular conditions, which may be caused in part by the stress of daily pain. Higher mortality risks are found mainly in those with more severe pain and in women, especially older women. Mortality in these cases may be due largely to fearful avoidance of activity, which can lead to obesity, inflammation, cardiovascular disease, osteoporosis, and depression, all of which are associated with increased mortality. To address these multifactorial issues, the World Health Organization (WHO) and other authorities emphasise the necessity of bespoke interventions addressing individual physical and mental needs [1].

Fortunately, yoga therapy is one of the most customisable holistic approaches to wellness as it includes so many different and variant elements across physical, mental, emotional, social, and spiritual domains. In a recent trial, participants with chronic LBP and multiple comorbid conditions reported a greater overall experience of improvement in the yoga group compared to the usual care group even when pain statistics remained similar between groups. Other studies have indicated moderate effectiveness of yoga for low back pain and related disability. As a non-pharmacological and non-invasive modality, yoga may be an excellent option for many people with non-specific LBP, especially older people, who are at higher risk not only for LBP but also for comorbidities and for adverse events from pain treatments. For clients with back pain potentially caused by more serious conditions, such as spinal fractures or cancer, yoga therapists are trained to recognize red flags and to signpost the clients to appropriate medical professionals.

In 2023 the WHO issued its first guidelines for non-specific chronic primary low back pain (persistent back pain lasting more than three months and not caused by another condition) in response to high costs and high prevalence at 90% or more of back pain cases presenting in primary care [1]. Yoga is explicitly included as a subset of exercise in these guidelines [2].

Yoga may be a cost-effective option for workers with musculoskeletal conditions including low back pain. A research-based workplace programme, Yoga for Healthy Lower Backs, revealed that yoga may reduce absenteeism by 70% and reduce NHS burdens with 72% cost effectiveness.

A 2017 study funded by the Welsh Health Economics Support Services found that yoga for employees could potentially increase health-related quality of life, decrease disability associated with back pain, and reduce sickness absences with a probability of 95% cost effectiveness. The yoga in the study incorporated a prescribed yet modifiable set of practices including [3]:

Specific movements that were dynamic, gentle, flowing, and originating from the spine
A balance of movement with stillness
Guided breathing and relaxation practices
Energy-releasing movements and hand mudras
Positive affirmations

With similar LBP-suitable activities, Minded Institute yoga therapy offers highly individualised integrated mind-body practices and education, for example in our training on yoga and mindfulness for chronic pain.

In addition, specially trained Minded yoga psychotherapists can interweave yoga therapy with psychotherapeutic approaches to fulfil multiple mind-body recommendations for LBP treatment. Yoga for back pain within our multidimensional model would answer the WHO’s call for whole-person care.

“The guidelines outline key principles of care for adults with chronic primary LBP, recommending that it should be holistic, person-centred, equitable, non-stigmatizing, non-discriminatory, integrated and coordinated.” – WHO (2023)

Low Back Pain: A Background

Impact: According to the WHO, approximately one in thirteen people (619 million) worldwide experienced low back pain (also called lower back pain) in 2020, making it the leading global cause of disability. The WHO expects this number to rise to approximately 843 million by 2050 as global populations’ body weights and lifespans increase.

Low back pain forces people to reduce their participation in their work, families, and communities, resulting in high costs to productivity, wellbeing, and health systems. These negative impacts are greater for people with chronic primary low back pain [1].

Causes: Back pain is termed non-specific when evaluations, tests, or scans do not reveal a cause. Non-specific low back pain is the most common type, but specific conditions can also cause or be associated with back pain, including [4]:

Muscle or ligament strain, including constant muscle tension that leads to spasms
Bulging, herniated, or ruptured intervertebral discs (which also frequently appear without pain)
Osteoarthritis, which can lead to spinal stenosis in some cases
Osteoporosis, which can lead to vertebral fractures
Ankylosing spondylitis, which is an inflammatory autoimmune disease

Risk Factors: While risk factors are not necessarily causes, they increase the likelihood of a condition. Risk factors of LBP include [4]:

Age (usually starting at 30-40 years and worsening after 50)
Physical inactivity leading to muscle weakness
Excess body weight, which can strain back muscles and potentially contribute to inflammation in some cases
Diseases such as arthritis or cancer
The lifting of objects inefficiently or without training the back to adapt to loads over time
Smoking, which increases risks for disc herniation (pressure from coughing) and vertebral fractures (osteoporosis from reduced blood supply to bones)
Stress, anxiety, or depression, which can cause difficulties on many levels including the physical (muscle tension), functional (chemical imbalances leading to inflammation), and mental (avoidance of movement or self-care)

It is important to remember that, while anxiety and depression correlate with back pain and potentially could act as part of a pain/stress “vicious cycle”, they are not necessarily the cause [5]. While it is encouraging to see the rise of interest in up-to-date neurological pain science among yoga professionals, it is disheartening to see an accompanying rise in online wellness sources implying that most pain is likely caused by psychological factors. Such an approach disempowers clients as they blame themselves for their pain and any lack of response to treatment. Responsible yoga therapists will acknowledge the complex multidimensional nature of pain and validate the client’s lived experience. Mental health issues comorbid with pain can be addressed effectively with yoga therapy, as seen in Minded courses on yoga skills for mental health, depression, and anxiety.

Treatments: WHO guidelines recommend non-surgical treatments for LBP including [2]:

Education for back pain knowledge and self-care
Exercise, including yoga
Some bodywork such as massage (but not traction)
Psychotherapy such as cognitive behavioural therapy
Pain medicines (but not opioids)

“A major challenge in minimising the burden of low back pain will be to facilitate identification of and access to effective non-pharmacological interventions in order to move away from harmful low-value health-care options, such as opioids.” – The Lancet Rheumatology (2023)

Why Use Yoga as an Adjunct Treatment for Low Back Pain?

Yoga as Exercise:

Studies have shown that yoga may match stretching and physical therapy (as physiotherapy is called in the US) and may surpass other types of exercise in its effectiveness for low back pain. Yoga as a conservative treatment for LBP appears in clinical guidelines, including the WHO guidelines mentioned above, as a subset of exercise.

The Institute of Health Economics in Alberta, Canada included yoga therapy in their 2015 clinical guidelines for chronic low back pain, the UK’s National Institute for Health and Care Excellence (NICE) included yoga for LBP in their 2016 guidelines, and the American College of Physicians and the American Pain Society followed in their 2017 guidelines. Based on a systematic review of research, the North American Spine Society published guidelines in 2020 for non-specific LBP. They found fair evidence for yoga providing medium-term decreased pain and increased function in mild chronic LBP (whereas several other popular exercise methods had poor or insufficient evidence) [6]. Australian standards also include yoga within exercise recommendations for LBP [7]. In 2022 Canadian authorities emphasised the need for back pain treatments to encompass not only exercise (including yoga) but also shared decision-making, patient education, and congruence between values and care, all of which are essential components of yoga therapy. Current NICE guidelines continue to include mind-body interventions under group exercise in the 2020 updated recommendations for LBP [8].

Yoga for Non-Specific Chronic Low Back Pain:

Precise yoga protocols have been researched for non-specific chronic low back pain, such as the protocol for the 2017 trial by Saper et al. This protocol’s practice sequence can be found in Supplement 2 in the trial report. This paper revealed that yoga therapy is equal to physiotherapy for pain and disability caused by LBP. The yoga and physiotherapy groups were less likely than the education group to use pain medication by the end of the study, and improvements from yoga and physiotherapy were maintained at one year. Adverse events were mild and were the same between yoga and physiotherapy [9]. A similar trial in 2011 showed that yoga classes are equal to stretching classes and more effective than a self-care book for decreasing pain and increasing function in chronic LBP for at least several months [10].

In both of these studies, the protocols included simple postures (done in movement or stillness), breathing exercises, and guided relaxation. It is interesting to note that the asana (posture) sequences included simple, gentle movements of the spine in all of its directions of motion (forward bending, backward bending, straightening, sideways bending, and twisting) and did not avoid any plane of movement. Perhaps this is one way that yoga can help to reduce pain sufferers’ fear of exercise and take advantage of the well-recognised healing benefits of movement for chronic LBP (not sudden acute pain, which will more likely benefit from short-term rest). Additionally, these protocols used asanas that could help to strengthen weakened muscles of the abdomen, back, hips/buttocks, and upper legs, all of which could help to balance joint function and support body weight more efficiently, thereby helping to reduce back tension and potentially raise mood and overall health through improved posture.

It is important with any protocol that the instructor be trained to assess individual range of motion, pain or distress levels, and precautions needed or contraindications present. Depending on the source of the back pain (whether known or unknown), certain movements that may be suitable for one client may be harmful for another. A qualified yoga therapist will be better able than most yoga teachers to modify protocols according to individual needs.

Yoga for Disc Health:

While back pain is multidimensional, physical causes can be prominent in many cases. One major physical cause of back pain is the degeneration and displacement of intervertebral discs (also called disks), the capsules of soft tissue between the vertebrae that absorb shock and allow movement in the spine. Intervertebral disc degeneration may not cause a problem in many people, but in other cases bulging or herniated discs can irritate spinal nerves and cause debilitating back pain. Some people with what appears to be non-specific low back pain may have symptomatic disc degeneration and not know it.

A 2015 trial indicated that properly adapted yoga can be safe for people with discs that are bulging (when the disc bulges beyond the line of its adjacent vertebrae) or herniated (when the semifluid inner core of the disc is squeezed into or beyond the outer layer of the disc) and can be beneficial for reducing disability in people with disc extrusions (a type of herniation in which the inner disc material breaks out of the disc and flows into the canal where nerve roots exit the spine), which can cause pain through pressure on the spinal nerves and through inflammation of the discs and surrounding tissues. The study suggested that yoga may help by [11]:

Reducing pressure on discs
Increasing blood circulation to spinal joints
Improving core stability and posture
Increasing safe range of motion and body awareness for more adaptive options in everyday situations
Decreasing fear, anxiety, and stress

This study emphasised the importance of instructor training and experience, such as that found among yoga therapists, so that the practices can be correctly designed for individual needs with proper precautions and contraindications in mind, and so that medical conditions can be recognised and clients signposted to medical professionals when necessary. The study also strongly advised caution for yoga teachers accepting students with LBP into general yoga classes, since yoga without suitable adaptations could potentially aggravate known or unknown disc problems.

Roles of Breath in Yoga for Back Pain:

As yogic wisdom and modern science show, breath is the bridge between body and mind. Slow controlled breathing in yoga has been found to reduce agitation and improve nervous system balance, which potentially could help to reduce back pain caused by mental and physical tension. Research suggests that yoga practices including pranayama activate the parasympathetic nervous system, which produces a relaxation response by shutting down the “fight-or-flight” stress response that is so pervasive in modern daily life and is strongly associated with many disorders including back pain. Further, when we enter the relaxation response state through breathing practices or meditation, we tend to reduce inflammation, which may also help to relieve back pain.

Additionally, training in conscious abdominal breathing, as is emphasised in Minded yoga therapy, may strengthen and mobilise the diaphragm, which could help to reduce LBP disability by coordinating intra-abdominal pressure and muscular forces, reducing the need for tension-producing overcompensation by back muscles, and improving posture for efficient weight distribution [12].

Yoga for Other Areas of the Body that Can Influence Back Pain:

Neck pain often accompanies back pain. Because physical and mental tension are so prominent in neck pain, one of the uniquely beneficial aspects of yoga for neck pain is the combination of physical exercises with physiological and psychological approaches to relaxation, such as slow breathing and guided imagery.

Shoulder pain is also often linked with back pain. Evidence indicates that whole-person approaches are superior to purely medical treatments. Some research suggests that meditation and yoga can help to reduce shoulder pain. The researched meditation approach was based on breath and body awareness, acupressure-like stimulation for directing attention, and guided imagery for relaxation. This is similar to many Minded practices, for example asanas with directed mindful attention on the breath and body, self-touch for awareness and acceptance, and guided relaxation options such as body scans or yoga nidra.

Low back pain may appear with or without sciatica, which is sciatic nerve irritation appearing as pain radiating from the lower back through the buttocks and legs. Disc degeneration is a major cause of sciatica, although other causes are possible. The 2015 study that showed yoga’s benefits for disc extrusion symptoms also showed benefits specifically for disc-related sciatica. Yoga therapy may be better than general yoga classes for people with sciatica, since yoga without well-informed adaptations could potentially aggravate sciatic nerve irritation.

Yoga as Mind-Body Modality:

NICE guidelines recommend programmes for back pain that combine physical and psychological elements, especially for people who have not responded to other treatments or who have limiting beliefs, avoidance behaviours, or major psychosocial barriers to recovery [8]. This biopsychosocial approach to pain care is highly recommended by the US Integrative Pain Care Policy Congress. Like the WHO, this congress calls for person-centred, wellness-focussed, and evidence-informed pain management [13]. The Minded Institute takes a similar stance, as seen in our article on yoga for chronic pain.

The International Association of Yoga Therapists (IAYT) recognises yoga’s ability to improve psychosocial health factors in many ways, including [13]:

Safety, effectiveness, low cost, low risk, few to no adverse side effects
Empowering clients through self-efficacy, self-regulation, and self-confidence for cost-effective long-term self-management and behavioural change
Ability to address multidimensional aspects of pain and comorbidities
Social and behavioural elements for mental wellness without “group therapy” stigma
Accessibility and inclusivity for underserved and vulnerable populations

Yoga’s multifactorial benefits for low back pain are supported by research including a 2013 study that investigated which aspects of yoga may have made it superior to self-care for reducing disability in chronic LBP [14]. These aspects included:

Self-efficacy
Decreased sleep disturbance
Time spent on back exercise
Conscious awareness of the body and stress

Minded yoga therapy similarly emphasises a whole-person approach, making it a strong choice for a primary conservative measure to help with low back pain. If you suffer with back pain, find a Minded yoga therapist near you.

To learn more about yoga therapy for back pain, join Minded’s upcoming CPD: Yoga Therapy and Mindfulness for Chronic Pain.

To become a yoga therapist, consider enrolling in our yoga therapy training, or to become a yoga psychotherapist, you may want to enroll in the yoga psychotherapy training.

References:

[1] World Health Organization (2023). WHO releases guidelines on chronic low back pain. www.who.int. Accessed 28 March 2024. https://www.who.int/news/item/07-12-2023-who-releases-guidelines-on-chronic-low-back-pain

[2] World Health Organization (2023). WHO guideline for non-surgical management of chronic primary low back pain in adults in primary and community care settings [PDF]. Accessed 28 March 2024. https://iris.who.int/bitstream/handle/10665/374726/9789240081789-eng.pdf?sequence=1

[3] Hartfiel, N. et al. (2017). Cost-effectiveness of yoga for managing musculoskeletal conditions in the workplace. Occup Med 67(9): 687-695. doi: 10.1093/occmed/kqx161

[4] Mayo Clinic (2023). Back pain. www.mayoclinic.org. Accessed 28 March 2024. https://www.mayoclinic.org/diseases-conditions/back-pain/symptoms-causes/syc-20369906

[5] Ingraham, P. (2023). Does anxiety cause back pain? www.painscience.com. Accessed 28 March 2024. https://www.painscience.com/blog/does-anxiety-cause-back-pain.html

[6] North American Spine Society (2020). Evidence-based clinical guidelines for multidisciplinary spine care: Diagnosis and treatment of low back pain [PDF]. Accessed 28 March 2024. chrome-extension://efaidnbmnnnibpcajpcglclefindmkaj/https://www.spine.org/Portals/0/assets/downloads/ResearchClinicalCare/Guidelines/LowBackPain.pdf

[7] Australian Commission on Safety and Quality in Health Care (2022). Low back pain clinical care standard [PDF]. Accessed 28 March 2024.

chrome-extension://efaidnbmnnnibpcajpcglclefindmkaj/https://www.safetyandquality.gov.au/sites/default/files/2022-08/low_back_pain_clinical_care_standard.pdf

[8] National Institute for Health and Care Excellence (2020). Low back pain and sciatica in over 16s: assessment and management. NICE guideline [NG59]. Published: 30 November 2016. Last updated: 11 December 2020. www.nice.org.uk. Accessed 28 March 2024. https://www.nice.org.uk/guidance/NG59/chapter/Recommendations#non-invasive-treatments-for-low-back-pain-and-sciatica

[9] Saper, R. et al. (2017). Yoga, physical therapy, or education for chronic low back pain. A randomized noninferiority trial. Ann Intern Med 167(2): 85-94. doi: 10.7326/M16-2579

[10] Sherman, K. et al. (2011). A randomized trial comparing yoga, stretching, and a self-care book for chronic low back pain. Arch Intern Med 171(22): 2019-2016. doi: 10.1001/archinternmed.2011.524

[11] Monro, R. (2015). Disc extrusions and bulges in nonspecific low back pain and sciatica: Exploratory randomised controlled trial comparing yoga therapy and normal medical treatment. J Back Musculoskelet Rehabil 28(2): 383-392. doi: 10.3233/BMR-140531

[12] Sannasi, R. et al. (2023). Diaphragm and core stabilization exercises in low back pain: A narrative review. J Bodyw Mov Ther 36: 221-227. doi: 10.1016/j.jbmt.2023.07.008

[13] Pearson, N. et al. (2020). White paper: Yoga therapy and pain—How yoga therapy serves in comprehensive integrative pain management, and how it can do more. Int J Yoga Therap 30(1): 117-133. doi: 10.17761/2020-D-19-00074

[14] Sherman, K. et al. (2013). Mediators of yoga and stretching for chronic low back pain. Evid Based Complement Alternat Med 13 (Article ID 130818, 11 pages). doi: 10.1155/2013/130818

Yoga for Back Pain