Yoga Is The First Step In Managing Back Pain: NICE Update Their Guidelines

Back pain is the second most common reason for long term sickness in the UK and costs the NHS millions annually. Yet it is often very difficult to identify an origin for the pain and up to 85% of sufferers show no identifiable cause. These cases are lumped under the umbrella of 'non-specific back pain'. This type of is pain is from cumulative injuries, caused by a variety of factors including poor posture, repetitive movements, too much sitting, obesity and psychosocial considerations.

Yoga included as a non-invasive treatment

The latest NICE guidelines (published 6/1/17) for low back pain and sciatica recommend group yoga or tai chi classes as a main component of non-invasive treatment! This is brilliant news as it means the evidence is finally there to support what many yogis have known for years: yoga can be a very effective treatment for back pain. But what is it about yoga that makes it so powerful? For answers we need to look at the body's response to pain a little more deeply.
Unfortunately because it is hard to pin down a cause of back pain it is often challenging to treat, leading to chronic pain conditions for millions of people. Once the pain becomes chronic a number of changes occur in the nervous systems, muscles affected and psychological state. These changes cause feedback loops which amplify or even cause pain even if the original cause has healed.

How yoga helps with back pain

One of the most significant feedback loops is the interplay between fear/hypervigilance of pain, muscle tension as a result of the fear, and ongoing pain which creates further inflammation and more pain. A schematic of this relationship can be seen in Figure 1, which clearly shows how treatment is unlikely to be successful unless these secondary factors are also addressed. The NHS and NICE now view chronic back pain as a multifaceted condition which requires a multifaceted treatment package.

Figure 1. Chronic pain cycle

The good news is yoga can form a major part of that multifaceted treatment package in one go! One key piece of advice to those with chronic back pain is 'keep moving'. Yoga definitely helps with that, improving both core strength and flexibility. Increasing core strength is key because it reduces the load on the spine and back muscles, increasing flexibility and allowing people to move more freely.

But, that's not all. At the heart of yoga is the connection of mind and body through breath which promotes relaxation and much greater internal awareness. Or in medical terms, yoga stimulates the parasympathetic nervous system or PNS (the system responsible for rest, digestion and healing). Different elements of yoga stimulate the PNS in different ways allowing all the elements of the secondary chronic pain feedback loop to be targeted simultaneously (see Figure 2).

  • Pranayama connects mind and body, promoting relaxation. 

  • The asanas teach the body how to regulate and reduce muscle tension in key areas 

  • Meditation: teaches the mind to draw away from hypervigilance, easing over-sensitised neural pathways and decreases inflammation in the body.

  • Figure 2. How yoga targets the chronic pain cycle.

    Reducing cost & the use of opiates

    Additionally the shift away from painkillers and towards yoga as a first line intervention for back pain could dramatically reduce the amount of opiate painkillers prescribed. This is a huge benefit to patients as it avoids the potential side effects, and addiction risks of opiates. It also benefits the NHS in terms of reduced drug costs and demands on clinician time.
    To conclude, the inclusion of yoga in the NICE guidelines for low back pain and sciatica is a huge breakthrough for patients and for those of us who dream of seeing yoga thoroughly integrated into the NHS. Yoga has great potential as an intervention for many conditions and I hope this will be the first of many more NICE.
    This blog was written in conjunction with the Minded Institute who are running a course on yoga therapy for low back pain and sciatica in April.


How the Shape of Your Bones Affects Your Yoga Practice

In yoga we tend to talk a lot about muscles and connective tissue, but very little about bones. We talk about soft tissue being tight, stiff or flexible and how to change it. Often there is the underlying assumption that if you are diligent enough with your yoga practice then you will eventually be able to do any pose you wish. This assumption might be true if soft tissue was the only limiting factor in yoga. But that simply isn't the case, sometimes you come up against the hard portion of your anatomy: Bone.

Skeletons are the framework for yoga practice. They are all uniquely proportioned and as yogis they define our individual limits. If your legs are much longer than your torso you will never be able to touch your nose to your toes in a forward fold no matter how flexible your hamstrings are. Or, if you come up against a hard 'bone on bone feeling as you move into to pose that is your anatomical end point. Hips are a key area where we can come up against this 'bone on bone' feeling and I'm going to explore the reasons in the remainder of this post.

Figure 1, below is of  the top of two femurs (thigh bones). It shows the heads (which fit into the hip socket) and the necks attaching to the shaft of the femur, This picture is commonly used to illustrate the anatomical extremes of femur development. The bone on the left has a small head, and a long slim neck coming straight out from the shaft. The bone on the has a large head with a short thick neck, angled forward from the shaft. It's easy to see how these variations could mean different ranges of movement for the individuals involved. However, the shape of femur head and neck are only part of the story

Figure 1. Top view of two femurs

The shape and depth of the hip socket play a huge role in hip range of motion (ROM) as well. Figure 2.a, below shows scans from a hip imaging study . The blue shows a very shallow hip socket and the red a very deep one. Figure 2.b shows what happens to an individual's ROM when you take into account of the shape of the femur AND the hip socket. As can be clearly seen a shallow hip socket and narrow femoral neck allow a large ROM but with a deep socket and thick femoral neck the ROM is much reduced.

But what does this mean for us as yogis? Simply put if you have the hip configuration on the left you poses which require a lot of hip ROM e.g. pigeon or cow face are likely to be quite easy easy for you but you may struggle more with poses that require a lot of stability eg tree or warrior three. If you have the hip configuration on the right then pigeon may be very difficult but balancing on one leg might seem like the most natural thing in the world!

Figure 2. a) Shallow and deep hip sockets. b) Hip ROM combining shape of the femur and the hip socket.

The point here is not to beat yourself up one way or the other but simply learn to work with your body as you practice rather than trying to force yourself  into a position that might simply be impossible for your body. Give yourself permission to modify alignment to allow for your body geometry. Good yoga teachers should understand and respect this (provided you are not doing anything unsafe!) and be happy to provide modifications for you if you are unsure!

 For example, if you come up against a bone on bone feeling in pigeon then you could try moving the front knee out to  the side more to give yourself more space.Or if you feel stuck in janu sirsasana try bringing your torso more to the inside or outside of your straight leg.