Study Finds Yogā(sana) Can Help Back Pain, but Keep It Gentle, with These Poses by Allison Aubrey
New research finds that a yogā(sana) class designed specifically for back pain can be as effective as physical therapy in relieving pain. The protocol includes gentle poses and avoids more difficult ones. Comstock Images/Getty Images
If you’re tired of popping pain medicine for your lower back pain, yogā(sana) may be a good alternative.
New research finds that a yogā(sana) class designed specifically for back pain can be as safe and effective as physical therapy in easing pain.
The protocol was developed by researchers at Boston Medical Center with input from yogā(sana) teachers, doctors and physical therapists.
During the class, trained instructors guide participants through gentle poses, including cat-cow, triangle pose and child’s pose. Simple relaxation techniques are part of the class as well. More difficult poses, such as inversions, are avoided. A guidebook that details the poses taught during the class is freely available, as is a teacher training manual.
The findings, published Monday in the Annals of Internal Medicine, are in line with new guidelines for treating back pain from the American College of Physicians. The group recommends that people with back pain should avoid pain medicines if possible, and instead opt for alternatives such as tai chi, yogā(sana) and massage. As we’ve reported, those guidelines are aimed at people with run-of-the-mill back pain, rather than pain due to an injury or other diagnosed problem.
Who was in the study? Researchers recruited 320 racially diverse, predominantly low-income participants in the Boston area, all of whom had chronic low back pain. The study lasted one year.
What did participants in the study do? Participants were divided into three groups. One group was assigned to a weekly yogā(sana) class for 12 weeks. Another group was assigned 15 physical therapy (PT) visits. The third group received an educational book and newsletters. For the remainder of the year — roughly 40 weeks — participants in the yogā(sana) group were assigned to either drop-in classes or home practice. The PT group was assigned to either “PT booster sessions” or home practice.
The skinny: Researchers assessed changes in pain and function using a 23-point questionnaire. The participants in the yogā(sana) and physical therapy groups had about the same amount of improvement in pain and functioning over time.
When the study began, about 70 percent of the patients were taking some form of pain medication. At the end of three months, when the yogā(sana) classes were wrapping up, the percentage of yoga and PT participants still taking pain medication had dropped to about 50 percent. By comparison, the use of pain medication did not decline among participants in the education group.
“It’s a significant reduction,” says study author Rob Saper, director of integrative medicine at Boston Medical Center.
“I’m not recommending that people just go to any yogā(sana) class,” Saper told us. He pointed out that their research has helped nail down poses and relaxation techniques that are helpful and safe.
Saper says he chose to compare the effects of yogā(sana) with physical therapy because “PT is the most common referral that physicians make for patients with back pain. It’s accepted, it’s reimbursed, and it’s offered in most hospitals.”
Saper says if research shows that yogā(sana) can be as effective, “maybe yogā(sana) should be considered as a potential therapy that can be more widely disseminated and covered [by insurance].”
An editorial published alongside the study points out that treating low back pain is complicated and improvements documented in the study were modest.
“Any single treatment approach is unlikely to prove helpful to all or even most patients,” writes Stefan Kertesz of the University of Alabama at Birmingham School of Medicine and his co-author, Douglas Chang of University of California, San Diego. Nonetheless, as this new study has shown, “yogā(sana) offers some persons tangible benefit without much risk,” they conclude.
We all know that yoga does a body (and a mind) good. But up until recently, no one could really say with any degree of certainty why—or even how—it improves conditions as varied as depression and anxiety, diabetes, chronic pain, and even epilepsy.
Now a group of researchers at Boston University School of Medicine believe they’ve discovered yoga’s secret. In an article published in the May 2012 issue of Medical Hypotheses journal under an impossibly long title, Chris Streeter, PhD, and her team hypothesize that yoga works by regulating the nervous system. And how does it do that? By increasing vagal tone—the body’s ability to successfully respond to stress.
The Effects of Yoga on the Autonomic Nervous System, Gamma-aminobutyric-acid, and Allostasis in Epilepsy, Depression, and Post-traumatic Stress Disorder.
What Is Vagal Tone?
Most of us don’t even know we have a vagus that needs toning, but we most certainly do. The vagus nerve, the largest cranial nerve in the body, starts at the base of the skull and wanders throughout the whole body, influencing the respiratory, digestive, and nervous systems. Often thought of as our “air traffic controller,” the vagus nerve helps to regulate all our major bodily functions. Our breath, heart rate, and digestion—as well as our ability to take in, process, and make sense of our experiences—are all directly related to the vagus nerve.
We know when the vagus nerve is toned and functioning properly because we can feel it on different levels: Our digestion improves, our heart functions optimally, and our moods stabilize. We have an easier time moving from the more active and often stressful states of being to the more relaxed ones. As we get better at doing that, we can manage life’s challenges with the right blend of energy, engagement, and ease. When we can consistently maintain this flexible state we are thought to have “high vagal tone.”
…low vagal tone is correlated with such health conditions as depression, post-traumatic stress disorder, chronic pain, and epilepsy.
“Low vagal tone,” on the other hand, brings with it a sense of depletion. Our digestion becomes sluggish, our heart rate increases, and our moods become more unpredictable and difficult to manage. Not surprisingly, low vagal tone is correlated with such health conditions as depression, post-traumatic stress disorder, chronic pain, and epilepsy—not coincidentally, the same conditions that show significant improvement with yoga practice. Researchers hypothesize that it is vagal stimulation through yoga that improves these conditions.
To test their theory, the researchers investigated practices they believed would increase vagal tone. For example, they found that resistance breathing, such as ujjayi pranayama, increases the relaxation response, as well as heart rate variability (another marker of resilience). And a pilot study conducted on more experienced yogis showed that chanting Om out loud increased vagal tone and the relaxation response more than chanting it silently to oneself. Studies such as this one begin to reveal how different yogic practices impact human physiology in different ways.
A Pilot Study
In 2004 David Shapiro, Ph.D. and Karen Cline, B.A., published a study in the International Journal of Yoga Therapy (No. 14) with two objectives. First, “examine changes in self-reported moods and emotioinal states from before and after Iyengar Yoga classes and how they are affected by the practice of different types of Yoga poses” and second, “to deternine whethere observed changes in mood depend on one’s personality traits”.
“The main objective of [this] study was to test the hypothesis derived from Iyengar Yoga teaching and theory that the practice of back bends results in increases in positive emotional states (feeling happy or elated) and decreases in negative emotional states (feeling sad or depressed).” “To control for nonspecific factors, the effects of back bends were compared with the effects of two other typical Yoga practices (forward bends and standing poses). In this way, [it] could [be] determine[d] whether the expected changes in moods would be more pronounced in or specific to the practice of back bends.”
“By comparing the effects of the different class types within the same subjects, we could determine whether changes in self-reported moods from before to after a session would vary as a function of the specific focus on a given Yoga practice.” “A second aim was to test the hypothesis that mood changes asso- ciated with the different Yoga prac- tices would be related to personality traits. For this purpose, individual differences in anxiety, depression, and hostility were examined. These traits are related to emotional behavior and experience and may predict how a person’s mood changes with the practice of the different poses.”
“The practice of Yoga appears to result in increases in positive moods, decreases in negative moods, and increases in energy level regardless of the âsana practiced. Despite the effort and sustained physical exertion in Yoga, psychological wellbeing is enhanced after a Yoga class, which no doubt reinforces further participation. These effects tend to last at least for a few hours after a class. The specific poses also appear to result in differences in how moods are affected, although these results need to be replicated in a larger sample. The topic of social, psychological, and physiological mechanisms of movements is worthy of further attention. Moreover, the fact that mood changes may be in part dependent on one’s characteristic coping styles deserves further investigation. Back bends appear to be effective in increasing positive moods in general and in individuals who are relatively hostile or depressed. Yoga should be investigated for its potential clinical application in mood disorders and depression and in the management of hostility.”
Lower Your Shoulder Blades?
In his How to Heal (and Prevent) Shoulder Injuries (2007) Doug Keller begins, “Each time you lift your arms, your shoulder muscles- both big and small -initiate a dance full of subtle nuances. The complex interaction of those muscles, coupled with the unique structure of the shoulder joint, give our arms a wide range of motion. In fact, the shoulder is one of the loose joints in the body.”
“But this freedom of movement comes at a price: shoulders are vulnerable to injury both from sudden falls and from repetitive action such as throwing a baseball. The muscles of the rotator cuff, the most delicate movers of the shoulders, are particularly susceptible. But here is the good news: a regular, targeted asana practice can help you maintain healthy rotator cuffs by bringing awareness to your alignment, strengthening your shoulder muscles, and opening your chest.”
Early on, I struggled with where to place the scapula on bringing the arms over head. Directions to “lower the shoulder blades” appeared to be correct but this never felt quite right. Later, instruction to turn the upper arms by rotating triceps in, or biceps out, helped tremendously and eventually made my own teaching clearer.
One can hear John Schumacher giving a very similar instruction in his Urdhva Hastasana video. Within a Daily Bandha posting by Ray Long (Shoulder Kinematics in Yoga, Pt. 1), the video clearly shows that scapular rotation allows for maximum lift of the upper arm bone, collar bones and ribs. This very same action is also necessary when doing Downward Facing Dog, Full Arm Balance, Upward Wheel and others.
Doug Keller writes much the same and more in the PDF below, Shoulder to Shoulder. Explaining in detail, “When the arms come fully overhead, a slight reversal of direction has to take place: the shoulder blades should slightly depress, posteriorly tilt, and adduct in order to complete the motion to 180 degrees.” Keller precedes this with, “There is some elevation (‘shrugging’) of the shoulders as the arms come overhead, but not during the ‘setting’ phase of flexion and abduction.”
Try it, you’ll like it.
These instructions for Savasana are a modified version of Chapter 30 in Light on Pranayama (LoP). This script uses Mr. Iyengar’s words, but turns some of the descriptive passages into instructions so that when recorded, you can have an experience of Mr. Iyengar’s words leading you into Savasana when playing it back. All of this was originally prepared by Denise Weeks (Intermediate Junior II, IYNAUS Board member) for her students, whom she asked not to follow habitual patterns but instead to stay alert and implement the instructions.
So you know what to expect, instructions will take about 10-12 minutes. Be sure give yourself at least an additional five minutes of silence.
Parenthetical #s = page number and instruction number from LoP.
Bracketed info = where Ms. Weeks rearranged words or added transitional words.
Italicized font = Mr. Iyengar’s words that offer explanations or alternatives.
In many cases, these instructions use “your” where Mr. Iyengar used “the.”
1. Spread a blanket on the floor.
2. Before starting, remove constricting garments, belts, glasses, contact lenses, hearing aids, and so on. (234 #3)
3. [Remember, though Savasana means corpse, it] is intended for complete relaxation, and therefore recuperation. It is not simply lying on one’s back with a vacant mind and gazing, nor does it end in snoring. It is the most difficult of yogic asanas to perfect, but it is also the most refreshing and rewarding. (232 #1)
4. [To get started, visualize a straight line through the center of the blanket], and sit on the line with your knees drawn up and feet together. Gradually lower your back along the [imaginary] line, placing your body accurately so that the middle of your spine lies exactly on that line (235-236 #5)
5. Press your feet on the floor, lift your hips as well as the sacroiliac region, and manually, move the flesh and the skin from the back of the waist down towards the buttocks. (236 #6)
6. First adjust the back of the body. Then adjust the head from the front. From birth the back of the head becomes uneven, because babies lean to one side, resulting in one side of the head more compressed than the other.
Hence it is important to learn to adjust the head from the front and feel it from the back. (236 #7)
Make sure that your head is straight and parallel to the ceiling. If it tilts up, the mind dwells in the future. If down, it broods in the past. If it leans to one side, the inner ear follows. This affects the midbrain, and one tends to fall asleep and lose awareness. Learn to keep the head level with the floor so that your mind remains always in the present. (249 #23)
7. Fully extend one leg first and then the other. Join both the heels and knees. The joined heels, knees, crotch, center of the coccyx, the spinal column and the base of the skull should rest exactly in line. Then adjust the front of your body, keeping the center of the eyebrows, the bridge of the nose, chin, sternum, navel, and pubis’ center also on that line. (236 #7)
8. [Keep your body] straight and level. [To keep it straight,] draw an imaginary line straight along the centre of your forehead, eyebrows, root of the nose, middle of the lips, chin, throat and sternum, centre of the diaphragm, navel and pubis, and then through the space between the inner sides of the thighs, knees, calves, ankles and heels. To keep it level, start with the head, keeping your ears, the outer corners of the eyes, the lips and the base of the jaw bone parallel to the floor. Stretch and adjust the back of the neck, so that it is centrally placed on the floor. (239 #8)
9. Pin the [inner point] of each shoulder blade to the floor. Roll the skin of the top chest from the collar bones towards the shoulder blades and adjust your back to rest perfectly on the blanket. See that the dorsal and lumbar areas of your spine rest evenly on either side and that your ribs spread out uniformly. Rest evenly on both buttocks. Rest the center of the sacrum on the floor so that the buttocks relax evenly. Draw a line between the nipples, the floating ribs and pelvic bones to keep them parallel to the floor. (239 #9)
10. Keep your feet together and stretch the heels’ outer edges; now let the feet fall outwards evenly, letting your big toes feel weightless and non-resistant… Persons with stiff legs may keep their feet about a yard apart, as this will enable them to keep the back rested on the floor.
Keep the back outer corner of your knees touching the floor. If [the legs] cannot rest use a folded blanket or pillow behind them. If the legs do not feel relaxed, place weights on the upper thighs (25-50 lbs). This removes tension or hardness in the muscles and keeps the legs quiet. (241 #10)
11. Keep your hands away from the body, forming a 15 – 20° angle at the armpits. Bend the arms at the elbows, [and touch] the shoulder tops with your fingers. Extend the triceps at the back portion of your upper arms and take your elbows as far as you can towards the feet. Keep your whole upper arm, with the outer edges of the shoulders and elbows, on the floor. Do not disturb the elbow points. Lower your forearms. Extend your hands from the wrists to the knuckles, palms facing upwards. Keep your fingers passive and relaxed, with the backs of the middle fingers touching the floor up to the first knuckles. See that the median plane of the arms, elbows, wrists and palms are in contact with the floor.
The feeling of lying on the floor should be as though the body is sinking into Mother Earth. (242 #11)
12. [Watch for tension in the palms, the fingers, the soles of the feet, and the toes, and] when and where it occurs, drop these parts back to their correct position. (242 #12)
13. Relax the back of your body from the trunk to the neck, arms and legs. Next relax the front of your body from the pubis to the throat, where emotional upheavals take place, and then from the neck to the crown. Learn to relax your entire body this way. (246 #13)
14. Experience the feeling of non-existence or emptiness in the pits of the arms, the inner pits of the groins, diaphragm, lungs, spinal muscles and the abdomen. The body then feels like a discarded stick. In correct Savasana the head feels as if it has shrunk. (247 #14)
15. [Be serene] in all parts of your body. Silence in the body will bring about silence in the mind. (247 #16)
16. Gently move the upper [eye] lids towards the inner corners of the eyes [to] relax the skin just above the eyes and create space between the eyebrows. Treat the eyes gently like petals of a flower. Raise the eyebrows just enough to release any tightness of the skin in the forehead. (248 #18)
17. [Keep your eyes] passive, and [keep your ears] quiet and receptive. (248 #19)
18. Keep the root of your tongue passive as in sleep and resting on the lower palate… Keep the corners of your lips relaxed by stretching them sideways. (248 #20)
9. [Release] tension from your facial muscles, especially around the temples, the cheekbones, and the lower jaw. [Experience] a feeling of quietness between the upper palate and the root of the tongue. [Let the] pores of the skin shrink [so that] your nerves can rest. (248 #21)
20. See that the breath flows evenly on either side of the nostrils. Start by inhaling normally, but exhale softly, deeply, and longer.
[If you feel] restless, perform deep, slow and prolonged in and out breaths until quietness is attained. The moment quietness is felt… stop deep breathing and let the breath flow by itself. (249 #22)
21. When the art of exhalation is perfected, [you may] feel as if the breath is oozing from the pores of the skin on your chest, which is a sign of perfect relaxation. [Let] each out-breath take your mind towards your own self and purge your brain of all its tensions and activities. (249 #22)
22. Let the breath be like a string holding the pearls of a necklace together. The pearls are the ribs which move slowly, very steadily and reverently… When in that precise state, your body, breath, mind and brain move towards the real self, the Atma, like a spider returning to the centre of its web. Equanimity of mind, intellect, and self is felt at this juncture. (232 #3)
23. [Allow your mind to] dissolve and merge in the self, like a river in the sea… (250 #27)
24. [Experience a feeling of] equipoise between the two tides of emptiness of emotion and fullness of intellect. (251 #28)
25. [ …Some call this the “eternal now, beyond space and time,” in this state allow your body to be at rest as if in deep sleep, allow your senses to feel as if in a dream, but keep the intellect alert and aware.] (233 #8)
26. [In this state of discrimination, experience greater clarity and more and more relaxation. In this state, allow your doubts to vanish, feel a sense of illumination, and allow yourself to be merged in the Infinite.] This is the nectar of Savasana. (251 #29)
Set aside and additional 5 – 10 min. of silence, then end with more of Mr. Iyengar’s words.
27. Remain a silent observer until normal activity creeps into your brain and body. Gradually and gently open your eyes, which are at first unfocused. Remain in that state for a while. Then bend your knees, turn your head and body to one side and stay for a minute or two in that position. (252 #31)
28. In correct Savasana there is a minimum wastage of energy and maximum recuperation. It refreshes your whole being, making one dynamic and creative. It banishes fear (bhaya) of death and creates fearlessness (abhaya). (254 “Effect”)
29. [Now turn to the other side.]
30. [When you push into the floor to come up,] do not raise your head quickly. (252 #31)
31. [Sit quietly for a moment] and experience a state of serenity and inner oneness. (254 “Effect”)
Get a Hold of Yourself
Deep breathing has become increasingly important in my recovery from depression and anxiety because I recognize that shallow breath contributes to my panic. In fact, at my worst hours, I would use a paper bag to keep from hyperventilating.
The practice of deep breathing stimulates our parasympathetic nervous system (PNS), responsible for activities that occur when our body is at rest. It functions in opposite to the sympathetic nervous system, which stimulates activities associated with the flight-or-fight response. I like to the think of the PNS as the calm sister and the sympathetic nervous system as the non-sympathetic crazy sister on the verge of a nervous breakdown. You know that woman in the movie Airplane,
Of all the automatic functions of the body—cardiovascular, digestive, hormonal, glandular, immune–only the breath can be easily controlled voluntarily, explain Richard P. Brown, M.D. and Patricia L. Gerbarg, M.D. in their book, “The Healing Power of the Breath.” They write:
By voluntarily changing the rate, depth, and pattern of breathing, we can change the messages being sent from the body’s respiratory system to the brain. In this way, breathing techniques provide a portal to the autonomic communication network through which we can, by changing our breathing patterns, send specific messages to the brain using the language of the body, a language the brain understands and to which it responds. Messages from the respiratory system have rapid, powerful effects on major brain centers involved in thought, emotion, and behavior.
In their eight substantive chapters, the authors discuss several techniques of deep breathing to reduce stress and anxiety. They start off with three basic approaches which provide the building blocks for the others:
Coherent breathing is basically breathing at a rate of five breaths per minute, which is the middle of the resonant breathing rate range. I achieve this if I count to five inhaling and count to five exhaling. The five-minute rate maximizes the heart rate variability (HRV), a measurement of how well the parasympathetic nervous system is working. Brown and Bergarg explain that changing our rate and pattern of breath alters the HRV, which causes shifts in our nervous system. The higher the HRV the better because a higher HRV is associated with a healthier cardiovascular system and a stronger stress-response system. Breathing at a rate that is close to one’s ideal resonant rate (around five breaths per minute) can induce up to a tenfold improvement in HRV.
Resistance breathing is exactly what its name suggests: breathing that creates resistance to the flow of air. Per the authors:
Resistance can be created by pursing the lips, placing the tip of the tongue against the inside of the upper teeth, hissing through the clenched teeth, tightening the throat muscles, partly closing the glottis, narrowing the space between the vocal cords, or using an external object such as breathing through a straw.
All that sounds a bit complicated to me. Breathing should be easy, right? So I simply breathe out of my nose, which, according to Brown and Bergarg, creates more resistance than breathing through the mouth. I do think it’s interesting when they explain that singing and chanting – all musical sounds created by contracting vocal cords—are forms of resistance breathing, and that is why they provide that relaxed sensation you can get meditating (if you CAN meditate).
Breath Moving is when, well, the breath moves. Courtesy of your imagination. Brown compares this exercise to an internal massage. I’m not sure I’d go that far. I like the real deal. However, I do think sending your breath on a little journey around your body – as long as it doesn’t get too lost — does help you keep your concentration on the exercise and not on your to-do list because counting to five can get a little old. For example, here’s part of a circuit the authors offer in their book:
•As you breathe in, imagine you are moving your breath to the top of your head.
•As you breathe out, imagine you are moving your breath to the base of your spine, your perineum, your sit bones.
•Each time you breathe in, move the breath to the top of the head.
•Each time you breathe out, move the breath to the base of the spine.
•Breathe in this circuit for ten cycles.
The history of Breath Moving is fascinating. According to the authors, the technique was created in large part by the Russian Christian Orthodox Hesychast monks around the eleventh century. The monks would teach the technique of moving the breath to the holy Russian warriors to help protect them from harm and to empower them as they defended their territory against invaders.