Looking back at the 2018 overview of low back pain studies in The Lancet, I wonder if much has changed in these past years. This leading medical journal announced that low back pain has increased worldwide. It stated that the medical approaches used in high-income countries, such as surgery, medication, injections and imaging, are not effective. The studies suggest further that exercise, education, and psychological therapies are most appropriate for the majority of low back pain cases. The pandemic hasn’t improved the prevalence of back pain. Instead, working from home may have increased back stiffness and pain. Back care treatments were interrupted and now often still have long waiting lists. Surprisingly, 24.4% of Covid survivors report back pain as a new associated pain (International Journal of Infectious Diseases, Sept. 22). Now more than ever, The Lancet’s simple guidelines can help us forward. This blog examines the treatment guidelines for low back pain, and explains how yoga therapy can help. With its emphasis on simple practices, breath optimisation and relaxation, it offers what the research prescribes.
The Lancet Report
The three articles written by the Low Back Pain Series Working group in The Lancet (published 21/03/18) reveal that non-specific low back pain has increased over the past 25 years. It grew to such an extent that it is now considered “the leading cause of disability worldwide”. The increase has been most notable in low- and middle-income countries. Symptoms of lower back discomfort occur among young and old alike: even 40% of 9 to 18 year olds have to cope with back pain. In high-income countries, research is proving that the medical approaches to low back pain are ineffective, despite being high-tech and expensive. Also anti-inflammatory drugs seem to have little impact.
Treating low back pain effectively is important because it comes at a high cost for the health care system and the individual. For the latter, there may be loss of productivity and extra costs, as well as psychological consequences that are hard to deal with.
Research suggests that exercise and education have a primary role in preventing back pain. When it comes to treatment, the studies advocate self-management, with only a very conservative use of medication, imaging and surgery. Self-management is specified as physical and psychological therapies. These include massage, exercise, acupuncture, spinal manipulation, Tai Chi and yoga. The psychological therapies that can help are cognitive behavioural therapy, progressive relation and mindfulness-based stress reduction.
For those who do not respond to the conservative programme, some epidural injections can be beneficial, at least in the short term. For continuing and disabling low back pain, surgery is still sometimes the best option. However, the long-term benefits are not always superior when compared to careful management. The authors report that “patients tend to improve with or without surgery so non-surgical management is an appropriate option for those who wish to defer or avoid surgery.”
The new guidelines for medical practitioners
In my own words:
-At first, give education and advice.
-Tell patients to stay active and stay at work.
-Limit imaging and only use it when you suspect a cause that is different from non-specific low back pain.
-Do not prescribe medication as a first choice.
-Using electrical physical interventions (such as short-wave diathermy or traction) is not advisable.
-The use of opioid analgesic medication is discouraged.
-Recommend exercise for chronic low back pain.
-Seek “biopsychosocial” help.
In an ideal world, specialised back care clinics would offer a self-management programme that comprises this variety of possible treatments. A general practitioner who has 10 minutes per patient, is unlikely to provide the appropriate time, care, advice and follow-up. Setting up back care clinics would give patients the opportunity to fill in an initial questionnaire and talk to a specialist. The specialist could then refer them to the appropriate treatment plan.
How Yoga Therapy can help
You can imagine that these new guidelines sound fabulous to a complementary practitioner like me, who approaches back issues with mindful practices, education and relaxation techniques.
Yoga therapy for back care tailors yoga movements, breathing and relaxation to the needs of the individual. The treatment differs according to the particular cause of back pain, fitness levels, and other health concerns of the patient. It also involves talking about the implications of the pain and which lifestyle changes can help. Similar to the “self-management” approaches, it requires the active involvement of the patient and is therefore empowering.
The result is greater body awareness, less stress, less or no soreness, and knowledge about what to do in case of a relapse. I have seen how yoga therapy, sometimes in combination with physiotherapy or other back treatments, can reduce and remove low back tenderness. I have observed how it empowers people and gives them new hope. The knowledge, active engagement and hope are very important at a time when persistent pain can give rise to frustration, fear and despair.
Education in my field of work also means discussing the movements that can exacerbate the condition. Often, though not always, patients automatically avoid movements that hurt. Sometimes, they keep hurting their back by putting shoes on a certain way, by bending down awkwardly, etc. Knowing how to change the habitual movement patterns that aggravate the pain is important. If you would like to receive some tips, subscribing to these blogs will give you the free “Keep Your Back Safe at Home Guide”.
yoga therapy addresses the underlying mental and emotional stress that can contribute to back pain. It does this by combining physical exercise with breathing, relaxation techniques, body awareness and concentration. Yoga therapy may not take away the need to have psychotherapy or to learn more about mindfulness, but it is a good start.
My advice in a nutshell:
- Firstly, if back ache keeps you up all night and does not improve in any position, please seek medical help as soon as possible. You want to rule out a cancer growth, an infection or fracture. Also loss of bladder/bowel control is an emergency.
- Back pain is a symptom. Reflect on what the cause could be: is it a repetitive activity, or lack of activity? Note the things you do every day, such as bending forward, sitting all day long, going on long car journeys, running on hard surfaces, horse riding, playing golf, etc. Can you change these activities? For example, take frequent breaks from your desk or sofa, change sports for a period. This blog gives tips on how to make a long car journey more back friendly. Also improving your posture is an important starting point. Alternatively (or in addition), can there be an emotional reason for your back issues? Is it stress or unhappiness that you have to address?
- Avoiding activities that hurt also means choosing the form of exercise that does not cause or increase soreness. It is true that we need to stay active, but the exercise has to be appropriate for the condition. Pain is a warning sign.
- Choose the exercise that you find enjoyable, but know that extreme sports are generally not conducive to healing. More favourable are walking, swimming, targeted exercises, pilates, and gentle, appropriate yoga.
- If you would like to try yoga for back pain, ensure it is right for your back condition. While some yoga poses will help, others may hurt your back more. When you have back pain it is better to choose specialised yoga therapy. Definitely avoid large classes with a dynamic yoga style.
Links to other blogs about yoga therapy for back care:
If you have non-specific low back pain that does not involve nerve pain, learn how to release low back tightness with this blog.
How to strengthen the back once pain has subsided is addressed in this blog.
Of course strengthening abdominal muscles is important too, and instructions on how to do this with back pain can be found in my video series here.
For low back pain that does include nerve pain (such as shooting pain down the leg), see here for more information.
- Use yoga, mindfulness techniques or meditation to calm your mind, to enhance concentration, and deal with mental or emotional stress. Some techniques are discussed in my blog “stressed out of your mind”.
- Find a yoga therapist to create a programme that is tailored to your particular back condition and health needs. My basic yoga therapy for back pain programme contains 5 sessions that teach you which movements to avoid and which to include in a daily practice. It also teaches you how to use the breath for greater calm and focus, and how to improve your posture.
- Finally, prevention is easier than cure. Prevent back issues by keeping your spine supple, by taking time to relax and to restore your energy and mental clarity.
Best of luck!