New thinking on back pain and why using yoga might be just what the doctor ordered.

540 million people worldwide or 7.3% of the global population suffer from back pain that limits activity in some way.[1]. Back pain is now the number one cause of disability globally and data shows that this is expanding, as years lived with low back pain disability increased by 54% between 1990 and 2015. In simple terms, it is a huge problem.

Increasingly, people are looking at Yoga for help with back pain or after experiencing back pain twinges. Research data over the last decade, shows Yoga is helpful for back pain and function. In 2017, NICE (National Institute for Health and Care Excellence) recommended group exercise classes, such as Yoga, as an early and cost effective treatment for low back pain and sciatica which means that GP’s may now be directing patients to Yoga classes too.

With the scale and common occurrence of back pain, you might think that medical science has a thorough understanding of what causes back pain and how to treat it. But advances in MRI imaging, neuroscience and further research into social factors affecting back pain have shown that it is not as straightforward as previously thought and there is still much to be understood about causes of low back pain, its treatment and more to find out about its prevention.

Do we really know what is causing low back pain?

Low back pain is a symptom not a disease and is defined by the location of pain, typically from below the lower ribs margins down to the buttock creases. It can be accompanied by pain in one or both legs.

Low back pain is extremely common; most of us will get it at some time and most people with a new episode of low back pain recover quickly, typically within a few weeks. However, for the majority of cases of low back pain, it is really not possible to identify any specific cause. Back pain without physical damage is classified as non-specific low back pain and accounts for the vast majority of back pain episodes.

For these cases of non-specific back pain, as painful as they are, the treatment approach is essentially to let it recover on its own - allowing recovery time without putting more stress onto the back, to take painkillers as appropriate and to keep comfortable in daily life activities. Within 2 -3 weeks, this approach will enough for most non-specific episodes of low back pain to recover.

For many people, an episode of non-specific back pain is a wake-up call to start paying more attention to health, to be aware of posture, the amount of time spent sitting perhaps in an uncomfortable way, at home as well as at work, and to incorporate some physical exercise into their life. Yoga can be the perfect solution for addressing all of these; health, awareness and exercise. People find that small or even large back issues may be reduced or completely resolved after they have started practising some suitable Yoga on a regular basis.

Low back pain with specific causes.

Low back pain symptoms can have specific causes, and where there is a specific cause it may commonly include the following causes, although this is not a complete list.   

Intervertebral disc bulges and extrusions. They are also called herniated discs or slipped discs, which is when part of the disc nucleus is pushed out of the outer intervertebral disc casing or the disc has developed a bulge.

Facet joint degeneration or syndrome. Facet joints are at each side of the back of the vertebrae and are involved in supporting the spine whilst allowing movement and providing stability. Changes around these joints from osteoarthritis, and/or inflammation, or proximity of one vertebra to another or stiffness limiting the motion of the joint can all lead to low back pain.

Changes to vertebral endplates (Modic changes). These are identified only by MRI scans and involve some alteration in the structure of the vertebra or vertebrae and the end plate of the neighbouring disc. They are thought to involve both mechanical (small structural damage) and bacteriological causes.

Spinal stenosis is a narrowing of the spinal canal through which the spinal cord or nerve roots travel.

The powerful nature of MRI and other imaging techniques sees what was previously unseen and investigations have found that, at least for people aged 50 or below, some MRI abnormalities are more common in those with low back pain than in those without. Those that had a reasonably strong association with low back pain include Modic change, disc bulge, disc extrusion and spondylolysis (a vertebral fracture). But these imaging findings are also common in people who do NOT experience pain. You can have a herniated disc, showing up on an MRI scan, but experience no pain. There is not enough evidence to show whether finding a condition on an MRI scan can predict the future onset or a pattern of low back pain occurring. NICE now do not recommend MRI scans as a routine for investigating low back pain although if anything, patients now expect them as a routine diagnostic tool.

Specific pathological causes of low back pain

A small proportion of people with back pain have a well understood pathological (disease) cause, such as a vertebral fracture, which would include spondylolysis, a tumour, or infection.

 Current understanding on back pain and risk factors

Long term or chronic low back pain is increasingly understood as a condition with a variable course over a long period of time, rather than as a number of episodes of unrelated occurrences. Around half the people seen with low back pain in doctor’s surgeries, have a path of continuing or fluctuating pain of low-to-moderate intensity, with some recovering, and some having persistent severe low back pain.

The identifiable factors associated with greatest risk of reporting back pain are physically demanding jobs, physical and mental comorbidities (other chronic health conditions), smoking and obesity.

The risk of low back pain becoming persistent and leading to disability increases with high initial intensity of pain, psychological distress and accompanying pain at multiple body sites.

Increasing evidence shows that pain mechanisms and the ways that someone feels pain (for example as affected by mood and beliefs) have important roles in the development of persistent disabling low back pain. Also of note is that disabling low back pain is over-represented among people with low socioeconomic status.

As more becomes understood about neuroscience and pain, research shows that in patients with chronic pain, there is more widespread activation of brain areas that are associated with the perception and production of pain. In brain smudging, brain cells beyond the area of the actual pain site can become activated. Wider activation of the brain can help to explain how chronic pain can be experienced as vague and widespread nature. This may be how it is activating the brain.

Most of these risk factors challenge the historical thinking that back pain is primarily a biomechanical or biomedical problem. This leads to interesting questions about how we look at serious and chronic back pain, and importantly, its treatment.

Widening the view

In recent decades, the biopsychosocial model has been applied as a framework for understanding the complexity of low back pain disability in preference to a biomedical approach.

The biopsychosocial model is a broad approach for examining health and illness, developed by George L. Engel, a specialist in internal medicine and psychiatrist, and dates from 1977. The model links disease to the interaction of many variable factors; biological factors (genetic, biochemical, etc.), psychological factors (mood, personality, behaviour, etc.), and social factors (cultural, familial, socioeconomic, medical, etc.). 

The Lancet report, "What low back pain is and why we need to pay attention" notes that “many factors can contribute to disabling low back pain including biophysical, psychological, social factors, genetic factors, and comorbidities. However, no firm boundaries exist among these factors and they all interact with each other. Available data suggests a similar multifactorial contribution to back pain seems to be important in all countries.”

The Lancet report recommends a broadening view on psychological factors which it says are often investigated separately, although there is an overlap of conditions such as depression, anxiety, catastrophizing (i.e. an irrational belief that something is far worse that it really is), and self-efficacy (i.e. belief in one's ability to influence events affecting one's life).

Fear of pain, termed the fear-avoidance model of chronic pain, is well established. It leads to avoidance of activities and can lead to disability. The Lancet report says that “This model has more recently been expanded to capture the influence of maladaptive learning processes and disabling beliefs on pain perception and on behaviours, suggesting that pain cognitions have a central role in the development and maintenance of disability, and more so than the pain itself. Therefore, some chronic pain treatments have shifted away from aiming to directly alleviate pain to aiming to change beliefs and behaviours.”

In this shift, there is the danger that the patient sees that the inference is that the pain is all in their head. It can only be distressing to be told that the pain is a psychological issue, will  be there without necessarily any resolution and the treatment now involves coping strategies.

 People with long term low back pain can often have on-going or intermittent pain in other body sites and more general physical and mental health problems than compared with people not reporting low back pain. “The combined effect on individuals of low back pain and comorbidity is often more than the effect of the low back pain or the comorbidity alone and results in more care, yet a poorer response to a range of treatments. 

Chronic disabling low back pain affects people with low income and short education disproportionally. In a UK study of over two thousand people, life-time socioeconomic status predicted disability due to any pain condition in older age, independent of comorbid conditions, psychological indicators and body-mass index. Again this challenges the way that we understood back pain as mainly a biomechanical problem.

It is leading, slowly, to developments and improvements in how chronic low back pain is being viewed and with the possibility that treatment will also change.

The Lancet, in its article “What low Back Pain is and why we need to pay attention” [1] includes key messages:

  • Low back pain is increasingly understood as a long-lasting condition with a variable course, rather than episodes of unrelated occurrence.
  • A biopsychosocial framework should guide management of low back pain – borne out by many existing clinical guidelines that provide similar recommendations for low back pain management.

Management and Treatment of Back Pain and Yoga.

In 2017, NICE published its revised Guidance to Low Back Pain and Sciatica which incorporated many of the recommended changes in diagnostic routes and treatment. This included the thinking around biopsychosocial treatment, based on evidence available at the time of the revision, although this is very much a shifting boundary of knowledge.

The Guidance was the first time that Yoga had been included as an intervention by NICE and was therefore a milestone in the UK, in terms of using Yoga to help a health condition.

For those who don’t or haven’t practised or tried Yoga, it is important to understand that Yoga has a huge breadth in terms of its physical practice ranging from heavily athletic or gymnastic practices or those that emphasise flexibility to essentially no physical exertion and working primarily or exclusively with the mind.

The good news is that through an increasing number of researched clinical trials, Yoga has been shown to have a positive effect. The nature of a good research trial means that the Yoga used is likely to have been carefully directed towards improvement in back health with avoidance of movement likely to cause back discomfort. For severe and chronic back pain, carefully directed Yoga practice is a sensible approach. 

Yoga as a mind body practice has a number of positives that help in treatment of back pain

  • Yoga was categorised by NICE as a mind body exercise. This makes it a good choice in line with a biopsychosocial treatment approach.
  • A structured progressive programme of Yoga in a group setting, incorporating advice on self-management, awareness of pain and comfort, posture, and positive messages ticks many of the psychological aspects
  • Practising physical aspects of Yoga helps people to develop a better awareness of their body and posture. It is not unusual for many people to forget about their level of physical discomfort when they sit at a desk and their work is based on mental activity.
  • Using the body and appropriate postures develops muscle strength in a gradual way. Practising movement encourages circulation, maintains a healthy range of movement in joints and improves disc health.  
  • Education on back pain and positive messages can be provided in a class on Yoga for back health or back care that is simply not possible in a 10 minute consultation with the GP. This of course is not due to any lack of desire from the GP but a problem with the limited time available for consultations.
  • Psychological approach –relaxation skills are commonly learned in Yoga and assist in mental and physical relaxation.
  • For participants, the experience of finding comfort for their back and without pain, challenges underlying beliefs about present and future pain and catastrophizing. Working with different parts of the body can provide a distraction from painful areas instead of dwelling on them.
  • Using focus on breathing in Yoga practice can provide a tool to manage pain, potentially painful movement and better relaxation.
  • Yoga is now being looked at for its positive mental health (PMH) effects. Most studies on this, observed ameliorations in PMH indicators due to Yoga practice.[2]
  • Social approach – group activity with others provides social interaction and anecdotally encourages participants to do more by being in a group than being alone. The social interaction of doing the activity together can help with fear of movement.
  • A non-medicalised setting is useful to help participants feel at ease and more relaxed, to meet others and enjoy the social interaction and to take positive action through gentle, appropriate Yoga for mind and body.

From personal experience of teaching Yoga, watching students in class and talking with them, I understand that the only prerequisite to beneficially using Yoga for back health is that the participant themself is there willingly to undertake this.

It is important that the participant is fully part of the treatment and is allowed to make decisions about what they do. By being guided through Yoga that is manageable, the participant feels positive and empowered about what they are doing. Moving to ease, as opposed to dis-ease, through manageable Yoga, practising relaxation, (a psychological as well as a physical practice), and using helpful breathing techniques to aid relaxation, challenges the underlying beliefs that someone may have about their back pain . This can and often does allow the person themself to find an improved relationship with their body, their heath and healing their back pain.

[1] The Lancet What low back pain is and why we need to pay attention – Hartvigson J and Hancock

[2] Modern postural yoga as a mental health promoting tool: A systematic review. Domingues RB Complement Ther Clin Pract. 2018

Barbara Dancer