Most likely, you’ve experienced it. We all have.
Lower back pain.
It’s one of the most common form of musculoskeletal injuries across the world.
It’s also the single leading cause of disability worldwide. 80% of people experience lower back pain at some point or another in their lives.
The effect of lower back pain is not only crippling on people individually, but has a significant impact on workplace productivity and the economy.
Research shows americans spend $50,000,000,000 per year on medicines for lower back pain, in the UK lower back pain is liable for the loss of one in six working days and in Sweden the number of workdays lost due to lower back pain has increased from 7 million (in 1980) to 28 million (in 1987).
Following this, people have long saught alternative options to help alleviate their symptoms of lower back pain, often finding that conventional advice given by doctors to take painkillers and rest simply do not work.
At our clinic, we see lower back pain on a daily basis, often associated with a difficulty mobilising comfortably, difficulties bending down, sleeping, playing sports and more.
As the lower back can almost be viewed as the ‘lever’ or ‘centrepoint’ of the body, it’s used in most day to day activities, and therefore when pain in the area arises it has a subsequent global impact on function.
Similarly to this, the general interest in yoga has increased over time. This isn’t a surprise, as there has been a vivid increase in people interested in health and wellbeing as a whole, with more restaurants offering healthier options of their staple meals, more awareness of health topics due to increasing scientific research, documentaries and information as well as easier access to these via social media.
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A Brief History of Yoga
Although yoga is most commonly known as a form of exercise, originally it was developed as a means for spiritual and psychological wellbeing, as well as a way to maintain a healthy and supple body.
Although there is no clear evidence of when the practise or discussion of yoga began, the first mention of it in written text is known.
A series of spiritual texts in India first mentioned yogic traditions and practises, the first being seen in Ring Veda, most likely comprised between 1500 and 1200 BC.
We see a description of Yogis and the impact they had on their society at the time:
“The Yogis of Vedic times left little evidence of their existence, practices and achievements. And such evidence as has survived in the Vedas is scanty and indirect. Nevertheless, the existence of accomplished Yogis in Vedic times cannot be doubted”. – Karl Werner, Yoga and the Rg Veda
The word ‘yoga’ itself came from the Sanskrit word ‘yuj’ which means ‘to join’ or to ‘reunite’, and it’s agreed that it has been accurately translated as ‘union’.
As time went on, the word yoga was used in more loose ways, and in the Bhagvad Gita, the most well known of the indian spiritual texts, yoga was classified into different subcategories, to describe different methods to enlightenment, including:
- Karma yoga: The yoga of action.
- Bhakti yoga: The yoga of devotion.
- Bhakti yoga: The yoga of devotion.
The first, and now known as the most foundational text of yoga, came about in 400 CE called the Yoga Sutra of Patanjali, written by a sage named Patanjali. It comprehensively discussed the practices of yoga, which include body and mind disciplines, the former of which we most easily recognise yoga as, described in the text as ‘hatha yoga’.
According to A Treatise of Yoga Philosophy, yoga started to enter modern era in the west in the mid 19th century.
The first commercial teacher of yoga in the west was Swami Vivekananda, and it grew over time to become a very popular methodology of spiritual growth, body control and exercise. The Swami was one of the first to have scientific researchers assess and study his work, which began the trend of assessing yoga as more than simply an indian tradition but more of a means for a specified goal, whether it be physical, mental or spiritual.
In 2014, the United Nations announced June 21st as International Day of Yoga, and a recent survey showed the number of Americans doing yoga has increased by 50% in the last four years, 9 out of 10 have heard of yoga and one in three have tried yoga at least once.
Yoga Entering the Healthcare Industry
In the 20th century, as more scientific evidence mounted for the effects of yoga on a variety of metrics related to wellbeing, the healthcare industry started to consider yoga as a possible means of treatment for specific conditions as well as a recommendation for overall health and wellness.
In the 1980’s, Dr. Dean Ornish was responsible for increasing the awareness of yoga around the world, as his studies showed lifestyle changes can make a significant positive impact on heart health.
Included in the studies is a recommendation for yoga, having studied it now for over 30 years with leading practitioners in the field, he is convinced it contributes well to long term health.
As of today, yoga has been studied on a broad range of conditions including anxiety, depression, pain, diabetes, heart disease, schizophrenia, metabolic syndrome and many more. As specialist musculoskeletal physiotherapists, we are interested on the effects of yoga on muscular and joint pain.
Today we will specifically look at the effects of yoga on lower back pain, the most common and most prevalent musculoskeletal disorder across the globe.
Yoga for Lower Back Pain: The Research
A study done as early as 2005 showed that when comparing yoga to conventional therapeutic exercise or a self-care book in a group size of 101 people (split into 3 respective groups) with chronic lower back pain, it showed improved outcomes on the Roland Disability Scale (back-related functional status).
At 12 weeks, the yoga group showed significantly improved markers with regard to back-related function compared to the exercise and book group, whilst the difference between ‘symptoms botherness’ was not statistically significantly different between any of the three groups.
The research showed that the improvements remained after several months, and was significantly more effective than the group who received the educational book.
The graph below (taken from the study) shows the improvement seen in the yoga group compared to the other two groups:
In 2008, a study was published in the Journal of Alternative and Complementary Medicine which looked at the effects of yoga specifically on veterans with chronic lower back pain.
There were 33 participants in total who completed the study, and how it worked was each participant completed a short number of surveys measuring a wide variety or markers (one being pain) before they started the yoga, and then at the end when they had completed 10 weeks of suitable yoga exercises.
The study states that “significant improvements were shown for pain…” and also that “the number of yoga sessions attended and the frequency of home practice were associated with improved outcomes”, giving some indication that compliance to the yoga programme over a period of time is required for ideal outcomes.
In 2009, a study was conducted looking at the effect of a specific type of yoga, lyengar yoga, on chronic lower back pain. A total of 90 subjects were divided into two groups, one which underwent bi-weekly yoga sessions for 24 weeks, and a control group who received standard medical care.
At 12 (half way), 24 (end of trial) and 48 (follow up) weeks a variety of questionnaires and pain scale measures were taken to see any changes in function and symptoms. The conclusions stated:
“Yoga improves functional disability, pain intensity, and depression in adults with CLBP [Chronic Lower Back Pain]. There was also a clinically important trend for the yoga group to reduce their pain medication usage compared to the control group”.
The graph below shows the results obtained from the study, specifically the change in pain symptoms amongst both tested groups:
In 2013, the Clinical Journal of Pain released a comprehensive meta-analysis of studies looking at how effective yoga is for long term lower back pain.
A meta-analysis is essentially one study that assesses multiple other studies. Hence the word ‘meta’, to mean, ‘beyond’. This particular study looked at 8 different trials up until the period of January 2012. The trials took place in the United States, the United Kingdom and India, and there were no language restrictions. The total number of people the study assessed was 967.
The analysis concluded:
“There was strong evidence for short-term effectiveness and moderate evidence for long-term effectiveness of yoga for chronic low back pain in the most important patient-centred outcomes.”
A second big study was published by the Clinical Journal of Pain entitled ‘A Systematic Review and Meta-analysis of Yoga for Low Back Pain’.
This study was similar to the one above, it was a study of studies (meta-analysis). This one looked at a total of 743 subjects, and had a similar conclusion as many of the other studies:
“The results of the present study indicate that yoga may be an efficacious adjunctive treatment for CLBP. The strongest and most consistent evidence emerged for the short-term benefits of yoga on functional disability.”
The research doesn’t stop there. As we discussed earlier, yoga has risen in popularity significantly in the recent past, and following from this, there has been a surge in assessing yoga’s potential, scientifically.
As a result, research papers are published almost every year and the promising results the research has thus far shown on its effect specifically on the world’s leading cause of disability has sparked curiosity amongst the scientific community, as it should do for physiotherapists too (more on this later).
In 2016, yet another large scale review study was conducted. This one include 1080 participants looking at 12 different trials.
The study concluded:
“There is low‐ to moderate‐certainty evidence that yoga compared to non‐exercise controls results in small to moderate improvements in back‐related function at three and six months. Yoga may also be slightly more effective for pain at three and six months… It is uncertain whether there is any difference between yoga and other exercise for back‐related function or pain, or whether yoga added to exercise is more effective than exercise alone”.
This resulted in a bit more ambiguity in the study of yoga and lower back pain, but even then the evidence was showing a trend towards positive effects of yoga for lower back pain relief. The consistency of the research results over the years in this manner is rare and promising. Furthermore, in 2017 we saw another study comparing yoga to to the methods of treatment with fascinating results.
The study, published in the Annals of Internal Medicine, assessed 320 people with nonspecific lower back pain and compared the effectiveness of yoga, physical therapy and education alone.
Participants were divided into three groups:
A weekly yoga class for 12 weeks
15 physiotherapy sessions
Education book and newsletter
For the approximately 40 remaining weeks of the year the yoga participants were either assigned to drop-in classes or home practice, and the physiotherapy participants were assigned to ‘booster sessions’ or home practice.
The results were reported succinctly:
“The yoga and physical therapy groups showed almost the same amount of improvement in pain and activity limitation over time. The improvements in pain and activity limitation in the yoga and physical therapy groups were also found at 1 year and were similar to each other. Yoga did not perform better than education in terms of improvement in pain and activity limitation at 3 months. However, participants in both the yoga and physical therapy groups were less likely to use pain medications at 3 months compared with the education group”.
The study did come with it’s obvious flaw, which the authors of the study recognised: each group knew what type of treatment protocol they were getting, and this potentially could have opened the participants up to to the effects of the placebo phenomenon or unconscious/conscious biases. That being said, the findings are still clinically interesting.
One of the findings that came from the study which is often overlooked, is the reduction in use of pain medication after treatment protocols.
When the study began, 70% of the patients were taking some form of pain medication. By the end of it, they were down to 50%. This was noted as a “significant reduction” by the studies’ author, and given what we know about the negative long term side effects of pain medication, it’s a huge plus.
So the research seems comprehensive and consistent in it’s findings, so then next natural question to ask it:
Why does it work?
Well, no one exactly knows, however, an extensive piece on yoga written by Vox author Julia Belluz explains it may be due to the fact that yoga causes ‘improved flexibility and muscle strength, as well as relaxation and body awareness’.
Yoga for Lower Back Pain: In Practice
We can extrapolate three main ideas from the research we currently have available on yoga and low back pain:
1. Yoga helps with acute (recent) and chronic lower back pain, with more evidence to suggest it helps with chronic (long-term) lower back pain.
- Most studies so far have been focussed on long term lower back pain, therefore more evidence is required on recent episodes of back pain and it’s response to yoga.
- I would still not recommended yoga for acute severe lower back pain. There are many causes for this condition however if you have had an acute severe accident, fall, injury or otherwise, it’s best to consult a medical professional before choosing treatment options.
2. The studies assessed a wide-ranging variety of yoga styles, postures and techniques, therefore we may assume the specifics are not as important as the principles.
- The principles of yoga include, but not limited to; stretching of the muscles, strengthening of the muscles, activating large and small muscle groups, muscle coordination and balance, regularly physical activity, a philosophy of wellbeing and betterment and working towards a specific goal.
- These principles supersede specific poses, although there is no doubt some specific movements are helpful specifically for the lower back (more below).
3. Generally speaking, yoga is as effective as traditional physiotherapy.
- The research suggest physiotherapy and yoga have similar effectiveness, and for physiotherapists this has important implications.
It means, effective physiotherapy for lower back pain should include the stretching, exercises and movements that are found in yoga together with traditional treatment, for maximal results. This is something we stress with importance at Tavistock Clinic.
- To find the exact yoga programme used in the 2017 study mentioned above, please view the yoga poses for lower back pain PDF by clicking here.
Resources on Yoga
If you have the inclination like I do to learn more, here are some further resources that are not only well created, but fascinating, comprehensive and informative:
1. The Science Behind Yoga Documentary
2. The Science of Yoga Documentary
3. For the most comprehensive book on human anatomy as it relates to Yoga, I recommend Yoga Anatomy by Leslie Kaminoff and Amy Matthews.
4. If you prefer not to follow the specified 12 week programme guided above and would like to follow a yoga for lower back pain youtube tutorial, you may find this routine by Adriene helpful:
5. You can contact Dr Alan Viau on this blog to experience how he has worked with people with lower back pain.
Of course, if any movements cause any pain of increased severity of symptoms, it’s important you stop.
Yoga has been shown to reduce pain symptoms for those suffering from lower back pain, and a structured programme is helpful to achieve the best results from Yoga.
Furthermore, yoga is shown to be as effective as physiotherapy, therefore it’s important for physiotherapy professionals to consider combining both methods when treating lower back pain for optimal results.
The principles of yoga, including physical activity, muscle strengthening and stretching, and utilising muscle coordination and balance, is an important aspect of it’s effectiveness.
A holistic approach to lower back pain is important, with yoga to be considered heavily as a treatment option for non-severe symptoms, and it is likely to be most effective for chronic non-specific symptoms.
Contributing Author: Kulraj Singh BSc MCSP HPC is Principal Physiotherapist at the Tavistock Clinic, tavistockclinic.com in UK who specialises in musculo-skeletal injuries, with a particular interest in sports and performing arts injury prevention and recovery.