Karen is a 53-year-old grandmother and bank employee who, until recently, experienced nagging lower back pain. After six months on muscle relaxants and two months on opioids, she still had pain a good deal of the time. Aware that working long hours at a desk and lifting a toddler when her core was “out of shape” was probably part of the problem, Karen discovered that by taking a walk on her lunch break she could get some relief—but only some. Then a coworker whose sciatica had been alleviated by therapeutic yoga recommended it to Karen. She decided to give it a try and signed up for my Tuesday evening back-care class.
Her choice was in line with clinical guidelines for the treatment of lower back pain recently released by the American College of Physicians. Having reviewed different noninvasive treatments for lumbar (lower back) pain and finding that medications provide only small to moderate improvements in pain levels, the ACP recommends first trying, for pain that lasts under 12 weeks, “nonpharmacologic treatment with superficial heat (moderate-quality evidence), massage, acupuncture, or spinal manipulation (low-quality evidence),” and, for those who suffer from chronic back pain, as Karen does, “nonpharmacologic treatment with exercise, multidisciplinary rehabilitation, acupuncture, mindfulness-based stress reduction (moderate-quality evidence), tai chi, yoga, motor control exercise, progressive relaxation, electromyography biofeedback, low-level laser therapy, operant therapy, cognitive behavioral therapy, or spinal manipulation (low-quality evidence).” The studies recommend anti-inflammatory drugs only if there is little response to these low-side-effect methods.
For Karen, yoga is affordable and accessible, and she now attends class twice a week. Karen likes the fact that I have training in yoga therapy and back care and worked alongside doctors and physical therapists. Therapeutic yoga classes are typically a bit more expensive than other yoga classes, but she feels it may be worth the small extra cost. In addition to her yoga classes, Karen has taken up warm-water swimming and begun a daily 20-minute vipassana (insight) meditation practice designed to help her cope with stress and pain. After several weeks of her new regime, Karen began to experience far less back discomfort and was able to lift her granddaughter without pain. Life, she now reports, is just better.
As a yoga therapist, I work with back health more than any other issue, and my public back-care classes are my best attended classes! What follows are some simple “do’s and don’ts” I gave to Karen and that I offer to others with chronic back pain as well. (Remember, not every yoga class is going to be appropriate for people with lower back pain. Talk to your doctor or physical therapist about what types of movement may be contraindicated for you, seek out a therapeutic class and teacher who is knowledgeable about back care, and let your teacher know about any pain, injury, or contraindications that you have.)
Don’t lose your natural lumbar curve. Slumping, or rounding the spine, perhaps because of spending long hours in an office chair that encourages bad posture, can take a toll on the back. In most yoga poses and throughout your day, whether sitting or standing, it’s important to maintain the natural inward curve in your lower back, to keep the back of your head lined up with the back of your pelvis (not dropping the head forward or back), and to keep your shoulders broad and stacked right over your hips. Even though your yoga teacher may cue a “flat back” (often to prevent you from losing your natural spinal curves by rounding or overarching the back), a totally flat back is not what we’re looking for. The spine’s natural curves—a slight inward curve of the lumbar spine (lower back), a slight outward curve of the thoracic spine (upper/middle back), and a slight inward curve of the cervical spine (neck)—are important for shock absorption and for optimal spinal health, so we don’t want them to go away!
Do practice healthier sitting and standing postures to help strengthen the back. Practice sitting tall, either in a chair or on the floor using props such as a stack of folded blankets or a yoga bolster while being mindful of maintaining the natural curve of your lumbar spine. Use this new posture any time you sit. When sitting or standing, utilize core support, with a slight lift of the lower abdominals and pelvic floor, and “think tall” with axial extension (upward lift) of the spine.
Don’t let the feet turn out when standing or walking. For many people, external rotation of the feet is both a result and a cause of shortening the piriformis (a culprit in sciatica). When this deep hip rotator is tight, the psoas (which runs from the lumbar spine to the top of the thigh) can also become tight, possibly resulting in lower back pain.
To help stretch a tight piriformis, practice supine pigeon pose, lying on your back and hugging one knee toward the center of your chest, or a figure-4 stretch, lying on your back and crossing one ankle over the thigh of the bent opposite leg. For a tight psoas, a supported bridge pose with a yoga block under your pelvis and a high or low lunge (anjaneyasana) practiced with a slight anterior (forward) tilt of the pelvis can help.
Do keep the feet parallel. If your toes tend to turn out, move your heels out enough so that they’re behind your toes. You want the second toes of each foot to be relatively parallel to each other and your knees tracking in line with the center of the foot. Do this when standing (whether in mountain pose, while working at a standing desk, or any other time), walking, or sitting.
(Note that while parallel feet is a good guideline for most people, it won’t be appropriate for everyone. See Bernie Clark’s article Should Your Feet Be Parallel in Mountain Pose and Down Dog? to learn more.)
Don’t round up from a standing forward fold with straight legs. This action can compress the discs of the anterior spine and aggravate back pain.
Do rise up from a forward fold with knees slightly bent, and use core support (a slight engagement of the pelvic floor and lower belly) as you lift your torso.
Don’t forget core strength. Yoga sequences often focus more on stretch than on strength. Stretching can be great for alleviating tightness in back muscles, and poses we might associate with a nice back stretch such as marjaryasana (cat-cow), balasana (child pose), ananda balasana (happy baby), and supine twists may feel good, but they don’t contribute much to building core strength, which is important for back health. To strengthen the back of a structure we must balance the support in the front. That’s why poses that incorporate abdominal and back strength are important for back health.
You can build abdominal strength with postures like paripurna navasana (boat), utkatasana (chair), plank and forearm plank, and vasisthasana (side plank), and back strength with postures like salabhasana (locust) and virabhadrasana III (warrior III). Strengthening abdominal and back muscles supports better spinal alignment, and these are the types of poses you might look for in a back-health-focused yoga class.
Caring for your back means developing healthy postural and movement habits and practicing postures and exercises that can build the muscle strength that will give your spine the support it needs. Now medical professionals are even beginning to recommend these methods over medication for the treatment of temporary or chronic low back pain, so if you suffer from back pain try putting down the pills (with your doctor’s OK), sitting up straight, moving about with more awareness, and hitting the mat for a strength-building, tension-busting yoga session to subdue that troublesome ache and find the joys of unimpaired motion once again.