Yoga Better than Injections for Low Back Pain

by Baxter

A July 18th New York Times blog post entitled Alternatives for Back Pain Relief surprised me when it proclaimed that a modern and widely used treatment method for low back pain is no longer considered effective, especially for chronic or long-standing low back pain. That treatment is the use of injections into the areas of pain. The injections usually contain the inflammation-decreasing drug cortisone, but can also have ingredients like morphine, ibuprofen and vitamin B12 in the mix. Over the years I have had many patients come to me with low back pain, and from their reports, the effectiveness of the injections never seemed particularly strong. For some patients with new acute low back pain, who experienced more serious signs and symptoms, like radiating pain to the leg or actual weakness, the injections more often seemed to provide some temporary pain relief.

However, several new studies have revealed that, when looking back at those patients treated with injections, the injections were not significantly more effective than no treatment at all. And one study indicated that those who did not get injections for a pinched nerve in the lower back fared better down the road than the patients who received an injection course.  In the commentary published in a recent issue of JAMA:

“Based on the available data, the JAMA authors conclude, doctors “should not” recommend injection therapy to their patients with chronic low back pain.” 

That may be a hard pill for some doctors to swallow, as there has been a steady increase in the use of injections for low back pain, mainly because it is relatively inexpensive, can be done as an outpatient in the office, has fewer risks compared to surgery, and makes the docs some bling. The possible one positive use of injections is that is does often provide some temporary relief of low back pain symptoms.

The New York Times post then went on to reference a recent systematic review of yoga for low back pain that we reported on here early this year. This study looked back at all of the best designed studies on the subject and concluded that there was “strong evidence of short term effectiveness of yoga for low back pain and moderate evidence of long-term effectiveness of yoga.”

But although the New York Times post mentions the clear benefit of yoga for short-term back pain, it does not emphasize the second claim that the study discovered: moderate evidence for yoga's help over the long term. I took another look at the study itself, and discovered an important caveat: the authors would only recommend Viniyoga style practice for long-term benefits, as the other yoga methods studied did not demonstrate the same benefits. As they state:

"The American Pain Society's guidelines recommend that clinicians consider offering yoga to patients with chronic LBP (lower back pain). However, this recommendation is limited to Viniyoga-style yoga as the net benefits for other yoga styles could not be estimated."

Now, I love Viniyoga and integrate its methods into my own practice and teachings, along with the wisdom of the Iyengar method and some other modern yoga styles I’ve learned over the years as well. But I suspect that some of the alignment-strong styles, like the Iyengar method, will prove to be helpful in the long run as well, but we will need better studies to bear that out. That said, for those who are not familiar with Viniyoga (a term coined by American yoga teacher Gary Kraftsow for the yoga he learned from T. Krishnamacharya and TKV Desikachar) I would recommend to you two books to learn more:

1. The Heart of Yoga by TKV Desikachar
2. Yoga for Wellness by Gary Kraftsow

For now, this is all good news for those of us dedicated to our practice. As one of my students said to me just this morning after class, it's his regular yoga class that keeps his back in the best shape over time since he first developed low back pain many years ago. I’d love to hear back from our readers about your experiences with yoga for low back pain, so send me your story!

And don’t forget, my live webinar on Yoga for Healthy Digestion starts today, Tuesday July 23, 2013 on Yoga U online! Click here to learn more about it and sign up to join me Tuesday and Thursday from  8:30 EST (5:30 PST).

Unclear on the Concept: Yoga as a Treatment

by Nina

Wet Handle Bars by Melina Meza

“A comprehensive review published in May in The Clinical Journal of Pain finds that there is “strong evidence for short-term effectiveness” of yoga against back pain, although whether the benefits last beyond a year is less certain.” — Gretchen Reynolds, NY Times Sunday Magazine

In this Sunday’s New York Times Magazine, there was a short article called “Spinal Trap,”
about alternatives for treating back pain. The subtitle was “How do you solve back pain? Don’t ask your doctor.” We’ve already heard from Baxter on this topic, when he confessed that he had little to offer his patients when he himself was a family doctor (see For the Young and Old: Back Care). And you’ll be hearing from him soon about the comprehensive review mentioned in the quote above.

For now, I’d just like to rant a bit about the second half of the sentence:

“strong evidence for short-term effectiveness” of yoga against back pain, although whether the benefits last beyond a year is less certain

At first, I was just confused. What does she mean it is less certain whether the benefits last beyond a year or not. If you’re doing yoga for your back pain and it helps your back pain, why wouldn’t it continue to help your back pain for as long as you kept practicing? But Brad pointed out to me the underlying confusion in this statement. He said, “She’s thinking about yoga like physical therapy. In other words, it’s like a “treatment” you get from the doctor, something you’d do for a couple of months to “cure” your back pain, but then when you felt better you’d stop the treatment. And then maybe the pain would come back eventually.”

Ah, so that's what she meant. But how completely unclear on the concept is that? Naturally, if something in your life is causing you back pain, whether it’s your posture at your desk or in your car, standing all day at your job, too much gardening, lifting your children, lack of exercise in general, stiffness in certain areas of your body, lack of strength in certain areas of your body, you can’t just go back to your old way of life and expect the results of a short session of yoga classes to see you through the rest of your life. That would be like thinking you could do a few months of weight training to get stronger, and then expecting that would keep you stronger for years to come.

Brad laughed and said, “Yeah, and it’s not like there’s a “cure” for aging.”

So, yes, we’re afraid that whether you are practicing yoga for back pain or another condition, or just, you know, for healthy aging in general, it’s going to require an ongoing commitment. But it’s free, has no unpleasant side effects, and oh, yeah, it actually works.

Friday Q&A: Which Forward Bends Are Safe?

Q: Nina's post earlier this week on how to get comfortable in forward bends was very informative (see Getting Comfortable in Forward Bends). But I was wondering whether both versions shown in the photos--the one with the rounded back and the one with the neutral spine--are safe for everyone.

A: Forward bends always need to be approached with awareness, caution and respect, especially for people with acute low back injuries or chronic low back conditions. People with herniated discs, facet irritation, or degenerative joint conditions in their spines may find that too much bending forward will increase their pain.

Several leg muscles attach to your pelvis and tight leg muscles can restrict the movement of your pelvis, which needs to be able to roll over the top of your hip joints. If your leg muscles are tight, sometimes sitting on a folded blanket can allow you to get the proper movement of your pelvis. However, if you have very tight hamstrings and don't have the ability to keep the natural curve in your low back as you bend forward, then the version with the bolster under your thighs may still be problematic.

Rounded Back Version: Could Be Problematic

In addition, there are some people with conditions for which forward bends are contraindicated, meaning that the risk is greater than the benefit. This includes individuals with severe osteoporosis as well as individuals who may have had vertebral compression fractures in the past. For them the neutral spine version with the chair or bench may be safe, but, again, be sure to  proceed with caution.

Neutral Spine Version: Proceed With Caution

In general, cultivating flexibility in your hip rotators and hamstrings can help you achieve a neutral spine in your forward bends, which will help keep your lower back safe.

—Shari

Featured Sequence: Low Back Care

by Baxter

Several weeks ago, I introduced some thoughts on low back pain and yoga (see here). As I mentioned, the majority of episodes of lower back pain are related to short-term issues of muscle strain or spasm, or other soft tissue and joint situations that usually resolve in six weeks or so. However, it is possible that a regular yoga practice or a special sequence directed at the lower back area can speed up that process and get you back on track a bit sooner. I have frequently observed that for students who come to class for the first time, acute low back strain often requires only a few sessions in my Back Care Yoga class before the student is well enough to return to or advance to a regular yoga class. In this setting, the variety of poses that may be helpful is a bit larger than with more serious lower back injuries or conditions. For example, you can be a bit more comfortable with some twisting and forward bending poses, which often have to be modified in the other situation.

This week I would like to give you a very brief sequence of poses to consider when addressing low back pain. (The poses in the sequence are all poses that we have already featured individually on the blog.) My intention is to add to this basic sequence over time. However, I have found that it is better to start with shorter practices and advance things as you are ready. Some of the poses in this sequence can be done dynamically, with you moving in and out of the pose with your breath, while others are done more statically, with you holding the pose for 30-60 seconds in most cases.

1. Reclined Hip Stretch Sequence (Dynamic). See here for a complete description of pose. 

2. Reclined Leg Stretch Sequence (Static). See here for a complete description of the pose.

3. Hunting Dog Pose (Static). See here for a complete description of the pose.

4. Half Dog at the Wall (Static). See here for a complete description of the pose.

5. Locust pose (Dynamic). See here for a complete description of the pose.

6. Knee to Chest pose (Dynamic). See here for a complete description of the pose.

7. Corpse Pose (Savasana) with Blanket Roll Behind your Knees (Static).

Notice how you feel after the practice and how you feel the next day. We’ll eventually add more poses to our back care routine, but these are a good start for you.

Featured Pose: Knees to Chest Pose (Apanasana)

by Baxter and Nina

Knees to Chest pose is a great way to warm up at the beginning of a practice or to cool down at the end of a practice, especially after a backbend or forward bend practice. This pose allows you to check in with the tightness or openness of your hip and buttock muscles and soft tissues, as you gently massage your lower back and abdomen. Because your knees are bent, the tension on the hamstring muscles is greatly reduced, making it safer than straight leg stretches for those nursing a sore or injured lower back. It’s very easy to do, doesn’t require props, and doesn’t take up much space, so this pose is one you can do almost any time or anywhere for quick relief of low back pain or discomfort after sitting for long periods of time, such as at a desk, in a car, or on an airplane.

This pose goes by different names Sanskrit names, depending on the yoga lineage. In the Krishnamacharya tradition, it is called Apanasana, with apana referring to the downward moving inner energetic wind of the body. So the pose is associated with anything that needs to exit the body from the perineum, including waste from the GI tract, as well as reproduction functions (it is sometimes recommended for menstrual irregularity, although Baxter knows of no evidence to support this). In other traditions, the pose is called Pavanmuktasana, which means wind-relieving pose. That name is self explanatory!

Baxter prescribes this pose for:

•    low back relief
•    tight hips
•    GI conditions where sluggishness is a problem (such as constipation)
•    general relaxation prior to Savasana

Instructions: Lie on your back with your knees bent and feet on floor.

Next, hold onto your knees with your hands, keeping your arms straight. On an inhalation, lift your feet up just a bit. Completely relax your leg muscles and let your arms do all the work.

Then, on your exhalation, bend your elbows and draw your knees toward your chest.

On your inhalation, straighten your arms and release your knees to the starting position. Repeat six times, moving with your breath.

Baxter recommends the dynamic version of this pose (moving with your breath) for low back pain, but if you are using the pose for other reasons and you prefer holding the pose for a longer period of time, you can keep your knees to your chest for 30 seconds to one minute.

Cautions: If you have knee problems, hold your hands behind your knees (between your calves and thighs). If the bones of soft tissues of your lower back or pelvis are sensitive, lie on a folded blanket or other padding.

Is working standing up too expensive? It could cost you as little as $10

Spending too much time sitting down is clearly unnatural, particularly if you sit down on very comfortable chairs. Sitting down per se is probably natural, given the human anatomy, but not sitting down for hours in the same position. Also, comfortable furniture is an apparently benign Neolithic invention, but over several years it may stealthily contributed to the metabolic syndrome and the diseases of civilization.

Getting an elevated workstation may be a bit expensive. At work, you may have to go through a bit of a battle with your employer to get it (unless you are "teh boz"), only to find out that having to work standing up all the time is not what you really wanted. That may not be very natural either. So what is one to do? One possible solution is to buy a small foldable plastic table (or chair) like the one on the figure below, which may cost you less than $10, and put it on your work desk. I have been doing this for quite a while now, and it works fine for me.

The photo above shows a laptop computer. Nevertheless, you can use this table-over-table approach with a desktop computer as well. And you still keep the space under the foldable table, which you can use to place other items. With a desktop computer this approach would probably require two foldable tables to elevate the screen, keyboard, and mouse. This approach also works for reading documents and writing with a pen or pencil; just put a thick sheet of paper on the foldable table to make a flat surface (if the foldable table’s surface is not flat already). And you don’t have to be standing up all the time; you can sit down as well after removing the foldable table. It takes me about 5 seconds to do or undo this setup.

When you sit down, you may want to consider using a pillow like the one on the photo to force yourself to sit upright. (You can use it as shown, or place the pillow flat on the chair and sit on its edge.) Sitting on a very comfy chair with back support prevents you from using the various abdominal and back muscles needed to maintain posture. As a result, you may find yourself unusually prone to low back injuries and suffering from “mysterious” abdominal discomfort. You will also very likely decrease your nonexercise activity thermogenesis (NEAT), which is a major calorie expenditure regulator.

With posture stabilization muscles, as with almost everything else in the human body, the reality is this: if you don’t use them, you lose them.

Low nonexercise activity thermogenesis: Uncooperative genes or comfy furniture?

The degree of nonexercise activity thermogenesis (NEAT) seems to a major factor influencing the amount of fat gained or lost by an individual. It also seems to be strongly influenced by genetics, because NEAT is largely due to involuntary activities like fidgeting.

But why should this be?

The degree to which different individuals will develop diseases of civilization in response to consumption of refined carbohydrate-rich foods can also be seen as influenced by genetics. After all, there are many people who eat those foods and are thin and healthy, and that appears to be in part a family trait. But whether we consume those products or not is largely within our control.

So, it is quite possible that NEAT is influenced by genetics, but the fact that NEAT is low in so many people should be a red flag. In the same way that the fact that so many people who eat refined carbohydrate-rich foods are obese should be a red flag. Moreover, modern isolated hunter-gatherers tend to have low levels of body fat. Given the importance of NEAT for body fat regulation, it is not unreasonable to assume that NEAT is elevated in hunter-gatherers, compared to modern urbanites. Hunter-gatherers live more like our Paleolithic ancestors than modern urbanites.

True genetic diseases, caused by recent harmful mutations, are usually rare. If low NEAT were truly a genetic “disease”, those with low NEAT should be a small minority. That is not the case. It is more likely that the low NEAT that we see in modern urbanites is due to a maladaptation of our Stone Age body to modern life, in the same way that our Stone Age body is maladapted to the consumption of foods rich in refined grains and seeds.

What could have increased NEAT among our Paleolithic ancestors, and among modern isolated hunter-gatherers?

One thing that comes to mind is lack of comfortable furniture, particularly comfortable chairs (photo below from: prlog.org). It is quite possible that our Paleolithic ancestors invented some rudimentary forms of furniture, but they would have been much less comfortable than modern furniture used in most offices and homes. The padding of comfy office chairs is not very easy to replicate with stones, leaves, wood, or even animal hides. You need engineering to design it; you need industry to produce that kind of thing.

I have been doing a little experiment with myself, where I do things that force me to sit tall and stand while working in my office, instead of sitting back and “relaxing”. Things like putting a pillow on the chair so that I cannot rest my back on it, or placing my computer on an elevated surface so that I am forced to work while standing up. I tend to move a lot more when I do those things, and the movement is largely involuntary. These are small but constant movements, a bit like fidgeting. (It would be interesting to tape myself and actually quantify the amount of movement.)

It seems that one can induce an increase in NEAT, which is largely due to involuntary activities, by doing some voluntary things like placing a pillow on a chair or working while standing up.

Is it possible that the unnaturalness of comfy furniture, and particularly of comfy chairs, is contributing (together with other factors) to not only making us fat but also having low-back problems?

Both obesity and low-back problems are widespread among modern urbanites. Yet, from an evolutionary perspective, they should not be. They likely impaired survival success among our ancestors, and thus impaired their reproductive success. Evolution “gets angry” at these things; over time it wipes them out. In my reading of studies of hunter-gatherers, I don’t recall a single instance in which obesity and low-back problems were described as being widespread.