Over 65 million people in the US live with lower back pain, with more than a third of people over the age of 18 experience severe enough back pain to seek professional help. It is estimated, that each year Americans alone lose 93 million days of work at a cost of $11 billion due to low back injuries. Another estimated $10-$20 billion is spent in direct medical expenses.
Traditional treatment modalities have not been shown to be consistently effective at treating lower back pain. Yoga therapy has much to offer in terms of addressing the issue because our focus is more global, considering the whole person, including life-style, personal outlook and self-awareness. In fact,
lower back pain is one of the number one reasons people seek out yoga and yoga therapy and studies have demonstrated the efficacy of therapeutic yoga in addressing lower back pain1.
The challenge is that the pelvis is a complex, weight-bearing structure. Many factors merge in the fulcrum of the lower back, sacrum and pelvic girdle applying various kinds of torque and pressure that can contribute to pain. Too much, too little or an asymmetrical shift in the spinal curvature puts stress on the nerves and the surrounding tissues and organs. The sciatic nerve, the largest nerve in the body originates at the lumbar and runs through the sacrum innervating the pelvis and legs.The major organs of elimination and reproduction sit in this same region and structural misalignment in the lumbar, sacrum or pelvis can impact proper vital function, as well as ambulation.
As bi-peds, the configuration or relative balance between the structures of the feet, legs and hips can feature as major contributors to lower back pain. Like-wise, excessive kyphosis or scoliosis in the mid and upper torso can put additional strain on the lower back and sacrum.
In many cases, psycho-emotional factors have been demonstrated to be primary, even more so than structural or postural imbalances2.
As yogis, we don’t have to look farther than the first, second and third chakras to recognize the many potential issues that can restrict prana and bind us up in this region.
To add to this murky equation, students often don’t know the source of their back pain, sometimes they’ll point to their hip or butt and say their back hurts. Even if they arrive at your door-step with an MRI report in hand, the story on paper is usually just one of the critical ingredients to consider.
Therefore, offering simple solutions when there are so many factors to consider is a dangerous business (ie: just do forward bends, or NEVER do forward bends, twisting is bad, backbends are good.) Yoga teachers and therapists need a healthy respect for and understanding of functional anatomy. In my experience, the best source for this information comes from non-asana biased anatomy experts (in other words, not necessarily your yoga teacher!)
I’ve found it to be incredibly helpful to detach from any ideas about the ‘perfect pose’ or ‘set of poses’ and to learn more about the how the body actually works optimally and what happens in the case of various pathologies. From there, I’ve come to understand why and how certain asanas, breathing and mindfulness practices can be sequenced and combined to facilitate positive change for a particular individual. It’s important that yoga teachers and therapists are well educated in order to keep students safe and create practices that are beneficial.
Chronic pain means there are musculoskeletal and psycho-emotional-neuro pathways that are set in a repetitive loop.
Since yoga is principally about transforming patterns that lead to duhkha, or suffering, this is definitely in our purview. Of course, the deeper the samskara, the pattern – the more challenging it is to transform. There has been much written on the debilitating effects of chronic pain. Depression, anxiety, a loss of freedom and ability to participate fully in life often accompany chronic lower back pain. A sense of isolation become a prevalent companion, as people find they are unable to participate in the social activities that bring them joy and connection with friends and family. Lack of restful sleep further aggravates the nervous system, making them more vulnerable to moods and emotional triggers and in fact, more susceptible to pain. We can become good at pain, the same way we can become proficient at many other things, through practice.
Chronic pain sufferers tend to shut down their awareness and attention to the areas that hurt – to move away from what causes discomfort (dvesha). Scientific studies show that the less kinesthetically aware a person is the higher their perceived pain levels. Increasing proprioception therefore actually decreases pain. Svadhyaya, self-awareness cultivated by attending to the areas that hurt and relinking or reconnecting the body with the mind via the breath as we do in yoga, can actually change the chronic pain pathways. The yoga sutra teaches that in order to alleviate suffering we must reduce avidya, our ignorance or lack of self-awareness.
The challenge for the yoga therapist is that we do not have the capacity to diagnose and often what will facilitate healing for one type of problem may aggravate another. Besides, rarely does someone come in with just one issue, they may have a lumbar disc bulge and be hypo or hyper-mobile; have an SI problem and scoliosis. This is just on the level of the annamaya, without even considering the psycho-emotional, life-style considerations, such as a stressful job, financial issues or divorce. Regardless of the source of the pain, the first gift is to help your clients find a position that is comfortable and relieves the pressure. Sitting or static standing are usually the most uncomfortable positions for back pain sufferers. I suggest starting in a supine position with the legs either resting on a bolster, pillow or even raised up on a chair. Diaphragmatic breathing that focuses on the exhale, releases subliminal contractions of body and mind. This allows the practitioner to learn new movements and move with less reactivity than when the body is tensely held and on hyper-alert.
Engagement of the deep abdominal muscles to control the exhalation breath begins a process of connecting the breath with core support. Positional comfort and breathing encourages relaxation. Comfort combined with conscious core support (sukha-sthira, ease and stability) sets the stage for healing by disarming the nervous system and releasing the fear/pain cycle. I’ve created the acronym, B.A.C.K. that can act as a foundation approach for healing, it’s a reminder that the Breath, Alignment, Core support and Kinesthetic or proprioceptive awareness are all integral to the healing process, especially as it relates to chronic back pain.
It’s also important for us to be humble and recognize when to refer our clients to seek further medical advice.
The more mindfully we teach our students to tune in and FEEL their body as they practice, the more they cultivate vidya – knowledge and this is ultimately the path to MOKSHA, freedom from suffering.