Yoga and Low Back Pain Part IV - Yoga Practice Guidelines for Low Back Pain
Hey Readers! I am so happy you are here. This is the final installment of my series on “Yoga for Low Back Pain.” In this installment, I will go over the recommended elements when implementing a yoga practice for low back health, based on the scientific research. If you have not read part I (click here), part II (click here), or part III (click here), I highly recommend that you pause and go back to read the earlier installments of this series before diving deeper into this post.
As described in part III of this series in detail, there is quite a lot of research that shows that a regular yoga practice can decrease the intensity of back pain, improve quality of life, and increase participation in various activities of daily living (ADLs). I would like to remind the readers (as explained in part III of this series) that much of the research also demonstrated positive gains whether participants completed a yoga practice, strength training practice, or physical therapy. For the purposes of this installment, however, I will primarily be going over practice guidelines as it pertains to yoga. For more information on strength training and/or physical therapy, please refer to my reference list at the end the of this post.
Yoga differs from most other forms physical exercise due to its holistic nature. A complete yoga program integrates physical postures, meditation, breathing practices, relaxation, and the study of yogic wisdom. Yoga is essentially a practice that aims to unite the student’s physical body with breath and mind. The purpose of yoga is to connect to yourself and others on a deeper level. There are so many styles and types of yoga, some with very high physical demands and others with very low physical demands. No matter the type of yoga being practiced (e.g. restorative, gentle, flow, etc.), the purpose of yoga typically remains the same – unity of body, breath, and mind. In this installment, I will go over the recommended guidelines and variables to consider when implementing a yoga practice for CLBP.
The best way to ensure a healthy low back is to have strong and flexible spinal, abdominal, hip, and thigh myofascia (i.e. muscles and surrounding tissue). Yoga postures, or asanas, help to build stability, strength, and mobility in your body’s myofascia. Of course, yoga for CLBP will vary person-by-person, but in general the following areas should be strengthened, stabilized, and stretched for the best possible outcomes.
The primary goals when working with the spine are to enhance stability and mobility. Recall from part I of this series that the deeper, shorter spinal muscles (e.g. multifidi) are primarily used for spinal stabilization (i.e. preventing unwanted motion in the spine), while the more superficial, larger muscles (e.g. erector spinae) are primarily used for larger, gross motor movements of the spine (e.g. side bending). It should be noted that while spinal mobility is super important, extreme spinal movements, especially in the lumbar spine, are neither necessary nor helpful. Spinal stabilization can be improved through targeted core work (discussed later in this post) and through spinal protective motions (e.g. drawing in, bracing), which are also discussed later.
Spinal mobility is enhanced via regularly taking the spine through the six general directions it can move – i.e. lateral flexion to the left and right (side-bending), rotation to the left and right, extension (i.e. bending backwards), and flexion (bending forwards). These movements are often referred to as the “6 moves of the spine.” To optimize extension mobility, postures such as sphinx pose, baby cobra, and cow stretch are fabulous. To optimize flexion mobility, postures such as child’s pose (balasana) and cat stretch are great. You can also alternate between cow stretch and cat stretch, moving with your breath. This cat-cow flow is a great way to reset and/or warm the spinal muscles. To optimize lateral flexion, poses such as a seated or standing side-bend are great. You could also do a side-bend from a supine position (known as bananasana), which reduces some of the compressive stress to the lumbar spine. To optimize spinal rotation, poses such as supine spinal twist, seated twist, or standing twists are preferred.
Activation of the abdominal muscles helps to stabilize the pelvis against the pull of extensor muscles such as the erector spinae. Also, a stable and strong core limits excessive and potentially stressful micromotions between the individual vertebrae of the spine. And, core stability and strength provides a firm base for the muscles of limbs to move efficiently. Thus, enhancing core stability and strength is super important for a healthy low back.
When participating in abdominal/core work, it is highly recommended that you use the following abdominal activation techniques, especially if you experience CLBP – abdominal hollowing (or drawing-in maneuver) and abdominal bracing. These activation techniques help to protect the spine and nearby joints by keeping everything locked and stable. The drawing-in maneuver involves gently contracting your belly button towards your spine, and this maneuver has been known to preferentially activate the transverse abdominis (TA) muscle. Recall, the TA is the deepest of the abdominal muscles, and it is responsible for stabilizing the spine and core. Abdominal bracing involves co-contracting the abdominal, back, hip, and thigh muscles (basically all the muscles described in part I of this series) in order to increase stiffness and to minimize movement in the lumbar spine, hips, and pelvis. However, be careful not to exert too much force when doing the abdominal bracing technique, as too much force can create larger than normal loads on the spinal joints. It is recommended that for normal, daily activities the abdominal bracing should be around 10% of the muscles’ maximum ability. While both of these techniques are appropriate for almost everyone to use, it is generally recommended that people new to exercise and yoga should master the drawing-in maneuver first in order to stabilize the spine. With this solid foundation in place, you can then work on the abdominal bracing maneuver to further stabilize the rest of the lumbo-pelvic hip complex.
Now that you know how to correctly recruit your abdominal muscles, let's go over the four core/abdominal exercises that are typically recommended to improve low back mechanics:
Mini curl-up. This can help to build strength and endurance in the rectus abdominis. In this exercise, one knee is bent with that foot on the floor and the other leg is straight on the floor. The hands are placed under the lumbar curve to maintain it. The chest, head, and perhaps the elbows lift up slightly from the floor after you engage the abdominal brace and drawing-in maneuver. The movement is subtle, just an inch or two upwards. Hold for about 10 seconds, take a brief rest, switch legs, and repeat.
Side plank. This can help to build strength and endurance in the internal and external obliques, transverse abdominis, QL, rectus abdominis, and lats. Engage the abdominal brace and drawing-in maneuver. There are lots of options for side plank. For example, you could lower one, or both, knees to the ground. Or you could straighten both legs with the feet on the ground in a staggered (typically easier) or stacked (typically harder) position. You can also do side plank from your hand with a straight arm or from your forearm. Try to keep your spine neutral.
Plank/Push-Up. Planks are great for engaging all the abdominal and core muscles, especially when the drawing-in and abdominal bracing maneuvers are used. Similar to the side plank, planks can be done from the hands or the forearms. While holding a plank with the arms straight, some of the body weight is taken by the feet due to the angled nature of this position. But, a forearm plank causes more weight to be borne by the core muscles. Thus, a straight-arm plank may be better for a weak core, but it challenges the wrists more, and vice versa with a forearm plank. Knees can come to the floor or stay lifted. If your body is looking for a little more spice, you can do push-ups from the straight arm plank position. However, if you are not a push-up person, just holding plank is fabulous for building strength in the core.
Spinal balance. Spinal balance can enhance erector spinae strength and endurance without overly compressing the spine. The are several variations to this pose. In any variation, the key is to maintain an abdominal brace and keep the lumbar spine as neutral as possible. You can lift just one leg behind you, which works the lumbar extensors on that same side, or you could add the contralateral arm in front of you, which adds work for the thoracic extensors and lats on the same side as the reaching arm. You can dorsiflex the ankle of the lifted leg to add challenge to the glutes and hamstrings.
Strengthening and stretching the muscles of the hips and thighs is also super important for a healthy low back. As discussed in parts I and II of this series, several hip and thigh muscles attach to, or near, the lumbar spine, potentially affecting the mechanics therein. Thus, exercises designed to strengthen and improve the mobility of the hip and thigh muscles can go a long way for low back outcomes. Exercises that are great for targeting the hips and thighs include: squats, lunges, clam shells, bridge, and single-leg balance poses. Please also refer to my previous blog series all about the gluteal muscles for more information on how to specifically train the muscles of the hips (click here).
Wow! A lot of information was presented about the low back over the course of this blog series. CLBP is unfortunately a super common issue across the globe and lifespan. Mechanical CLBP is usually the result of issues in the soft tissues of the low back area (e.g. muscles, tendons, ligaments, etc.). Often, the standard of care is to either prescribe pain medications and a education via a book about back pain, or to recommend surgery. But, the research seems to suggest that neither of these approaches are all that successful. Rather, the research seems to be pretty consistent in showing the physical activity and mindfulness of some type, whether from yoga, strength-training, physical therapy, or cognitive behavioral therapy, is the most helpful for reducing the symptoms of CLBP. If you choose to begin a yoga practice for your low back health, it is highly recommended that you work on strength and mobility for the spine, abdominals, hips, and thighs. Take your spine through its 6 movements regularly. Build strength in your abdominals by regularly practicing various plank poses and spinal balance. Improve hip and thigh mechanics by regularly strengthening and stretching the muscles therein. Obviously, there is no "one-size-fits-all" approach for dealing with the symptoms of CLBP. The recommendations offered in this blog series, especially the ones mentioned in this post, are simply suggestions based on the current research and theoretical landscape of human movement science. Ultimately, you are your best teacher. If in doubt about a yoga pose or beginning a yoga practice, check with your physician to see if yoga is safe your specific needs. Thank you so much for reading this series with me! It has truly been an honor to share this information with you all. I will be taking a little vacation from my blog posts, so no new blog posts will be released until Friday, August 6th. Monthly, not weekly, blog posts will resume at that time. Thank you for being such loyal readers!
As always, the information presented in this blog post is derived from my own study of neuroscience, human movement, anatomy, and yoga. If you have specific questions about your low back, please consult with your physician, physical therapist, personal trainer, or private yoga teacher. If you are interested in private yoga and/or personal training sessions with me, Jackie, email me at firstname.lastname@example.org for more information about my services. Also, please subscribe to my website so you can receive my weekly newsletters (scroll to the bottom of the page where you can submit your email address). This will help keep you "in-the-know" about my latest blog releases and other helpful yoga and wellness information. Thanks for reading!
~Namaste, Jackie Allen, M.S., M.Ed., CCC-SLP, RYT-200, RCYT, NASM-CPT
Biel, A. (2014). Trail Guide to the Body: A hands-on guide to locating muscles, bones, and more – 5th Edition. Books of Discovery. Boulder, CO.
Bramberg, E.B., et al. (2017). Effects of yoga, strength training, and advice on back pain: a randomized control trial. BMC Musculoskeletal Disorders. 18: 1 – 11.
Bushnell, M.C., Ceko, M., & Low, L.A. (2013). Cognitive and emotional control of pain and its disruption in chronic pain. Nature Reviews Neuroscience. 14(7): 502 – 511.
Carson, J., Carson, K., & Krucoff, C. (2019). Relax into Yoga for Chronic Pain: An Eight-Week Mindful Yoga Workbook for Finding Relief and Resilience. New Harbinger Publications, Inc. Oakland, CA.
Chang, D.G., et al. (2016). Yoga as a treatment for chronic low back pain: A systematic review of the literature. Journal of Rheumatology and Orthopedics. 3(1): 1 – 8.
Cherkin, D.C., et al. (2016). Effects of Mindfulness-Based Stress Reduction vs Cognitive-Behavioral Therapy and Usual Care on Back Pain and Functional Limitations among Adults with Chronic Low Back Pain: A Randomized Clinical Trial. Journal of the American Medical Association. 315(12): 1240 – 1249.
Clark, B. (2018). Your Spine Your Yoga: Developing Stability and Mobility for Your Spine. Wild Strawberry Publications. British Columbia, Canada.
Colgrove, Y.M., et al. (2019). Physical and Physiological Effects of Yoga for an Underserved Population with Chronic Low Back Pain. International Journal of Yoga. 12(3): 252 – 264.
Groessl, E.J. et al. (2017). Yoga for Military Veterans with Chronic Low Back Pain: A Randomized Clinical Trial. American Journal of Preventative Medicine. 53(5): 599 – 608.
Harvard Health Publishing: Harvard Medical School. (2018). The safe way to do yoga for back pain. Article link here.
Nambi, G.S., et al. (2014). Changes in pain intensity and health related quality of life with Iyengar yoga in nonspecific chronic low back pain: A randomized control study. International Journal of Yoga. 7(1): 48 – 53.
Narain, P. & Sharma, I. Eds. (2018). Strengthen Your Back: Banish Back Pain, Increase Core Strength, Improve Posture. DK. Penguin Random House. New York, NY.
National Institute of Neurological Disorders and Stroke (n.d.). Low Back Pain Fact Sheet. Article link here.
Neumann, D.A. (2017). Kinesiology of the Musculoskeletal System: Foundations for Rehabilitation. 3rd Edition. Elsevier. St. Louis, MO.
Owen, L. & Rossi, H.L. (2013). Yoga for a Healthy Lower Back: A Practical Guide to Developing Strength and Relieving Pain. Shambhala Publications, Inc. Boston, MA.
Peloza, J. (2017). Lower Back Pain Symptoms, Diagnosis, and Treatment. Spine-Health. Article link here.
Roberts, C. (2016). Yoga for Low Back and Hip Health: Gentle and Restorative Yoga to relieve chronic low back, hip and sciatic nerve pain. Cyndi Roberts.
Saper, R.B. et al. (2017). Yoga, Physical Therapy, or Education for Chronic Low Back Pain. A Randomized Nonineriority Trial. Annals of Internal Medicine. 167(2): 85 – 94.
Sherman, K.J., et al. (2011). A Randomized Trial Comparing Yoga, Stretching, and a Self-Care Book for Chronic Low Back Pain. Archives of Internal Medicine. 171(22): 2019 – 2026.
Sherman, K.J., et al. (2013). Mediators of Yoga and Stretching for Chronic Low Back Pain. Evidence-Based Complementary and Alternative Medicine. 2013: 1 – 11.
Sorosky, S., Stilp, S., & Akuthota, V. (2008). Yoga and Pilates in the Management of Low Back Pain. Current Reviews in Musculoskeletal Medicine. 1: 39 – 47.
Spindler, B. (n.d.). Yoga for Lower Back Pain: Learn the Do’s and Don’ts. Yoga International. Article link here.
Telles, S., et al. (2016). Heart rate variability in chronic low back pain patients randomized to yoga or standard care. BMC Complementary and Alternative Medicine. 16: 279 – 286.
Telles, S., et al. (2016b). A Randomized Controlled Trial to Assess Pain and Magnetic Resonance Imaging-Based (MRI-Based) Structural Spine Changes in Low Back Pain Patients After Yoga Practice. Medical Science Monitor. 22: 3238 – 3247.
Will, J.S., Bury, D.C., & Miller, J.A. (2018). Mechanical Low Back Pain. American Family Physician. 98(7): 421 – 428.
Zhu, F., et al. (2020). Yoga compared to non-exercise or physical therapy exercise on pain, disability, and quality of life for patients with chronic low back pain: A systematic review and meta-analysis of randomized controlled trials. PLOS ONE. 1 – 20.