Yoga and the Management of Back Pain (Part 1)

Swami Bhaktipoornananda Saraswati

Why is it that 80% of the population suffer back pain at some time in their lives, many for a protracted period of time? Pain is like the warning lights on the dashboard of our car. When they light up, we investigate what is wrong and top up the oil, water, etc. Otherwise we'll wreck the car! Similarly, with the body it's no good wishing away the pain or just taking pain killers ad infinitum, that's like removing the bulb from the warning light. We need to discover the reasons for the pain.

Pain and injury

To my knowledge there is one major source of back pain and that is injury, and not necessarily the obvious injury resulting from falls, lifting, sports, etc. Even though we may not know it, many of us have injured our backs at some time in the past; strains and sprains can occur without our knowing that anything has happened. These small injuries stop the spine from moving properly, which leads to pain and inflammation at the site of the injured tissues.

Pain in the back is always associated with a part that is not moving properly. It can be very difficult to pinpoint because a small area of inflammation can have so many sensitive areas around it. Toxins are produced when there is inflammation. This affects surrounding tissues and we get a wide area of pain experience.

Back pain is so common because of our lifestyle and the way we use (or don't use) our bodies. We make very limited use of the back in our normal day to day life and also tend to adopt poor posture habits which often begin at school (where we sit slumped at a desk) or in the home (where we sit back in soft easy chairs with the spine in a forward curve). If we consider a small joint of the spine (Figure 1), it consists of facet joints on each side of the spine and a disc separating the adjacent vertebrae by sitting between the two vertebral bodies and cushioning them. This gap between the two vertebral bodies is designed to take weight. In a slumped posture, instead of the weight passing through these discs there is pressure on the facet joints of the spine which are not designed to be weight bearing. Gradually this can lead to localized pain at these joints and surrounding tissues, producing swelling from the loss of fluids from minute tears. This clears away in the healing process but leaves a residual area of scarring, hardened tissues and weakness.

However, not all back pain is from facet joints, it can come from soft tissues (tendons, cartilage, ligaments) and surrounding muscles and from the nerves as they emerge from the spinal column.

Inflexibility

A healthy spine is flexible and absorbs the impact of falling and lifting. Through bad habits our joints become inflexible and less able to respond to sudden movement or jarring. When we jar the back or move beyond our habitual range of movements suddenly, we damage the soft tissue of the spine.

Discs are surrounded by a lattice of criss-crossing ligaments that pass from one vertebra to the next. When we damage these tissues, they harden and are less able to move. Because of the limited movement of a joint in the spine, the joints above and below have to move more to compensate, resulting in increased wear and tear. So we then have a joint that has lost some of its elasticity and cushioning and is more prone to injury. The joints on each side do more work than they were designed for. The joints themselves can become quite irritated by subsequent strains and injuries and the surrounding muscles often go into spasm to protect the joint from movement. When we ignore this combination of irritation and muscle spasm, the spasm will become more intense and pull the two bones together to block movement completely.

Spasm

If the muscles around an injured joint are in severe spasm or persistently in spasm, then this can put so much pressure on the disc that it will bulge (prolapse) (Figure 2), especially where the ligaments across the outside of the disc have been strained and the disc has been traumatized by poor posture or from taking extra work because of other limited joints in the vertebral column. When we release the muscles that are in spasm, the bulging disc can retract back into its normal space.

Disc deterioration

When a spine has been immobilized for a long time through pain, the soft tissues around the spine shorten and disable the springing effect that a healthy spine has by virtue of its spongy discs. When we stretch the shortened tissues out again, the discs also need their encircling girdle of ligaments to be stretched. When a whole section of the spine becomes stiff and solid, the discs start to shrivel and collapse or completely disintegrate, and so we lose height. This leads to increased strain on the bony facet joints because they are closer to each other. They can jam up, causing more pain and discomfort. Also, because the disc is not as thick as before, the ligaments that surround it seem too long. They can no longer hold the joint firmly. The joint is then unstable and more easily injured. The long erector muscles on each side of the spine have no way of holding the individual vertebrae in place, that is the job of the intrinsic muscles that link each vertebra to its adjacent vertebra. If the long back muscles are in spasm, as they usually are when we are in pain, they paralyse these intrinsic muscles and threaten the stability of the spine.

In my own experience of progressive injury I jarred my back when I fell onto my buttocks whilst snow skiing and again falling downstairs. Because I was not using my spine well (poor posture and general lack of muscle tone), there was damage to the soft tissues. About two years later I strained it again lifting. Six years later I strained it badly pulling on a rope (rotation) and needed a week or two of rest. Another six years passed before I strained again pushing a wheel barrow then hoeing (3 years later) when I had excruciating pain for many months from a prolapsed disc. Then another 8 years on I was stepping into my trousers and the disc 'went' again.

So the last spectacular strain was from a very minor movement brought on partly by weakness from resting for several months because I had been ill, and partly because of my susceptibility to ligament strain just prior to menstruation. (This is a known syndrome that involves changes to the ligaments similar to those that occur during pregnancy, but occurring as part of the menstrual cycle.) The prolonged inactivity had led to weakened musculature generally, but especially these intrinsic muscles. This left my previously injured disc very vulnerable in an unstable joint, and so the simple forward bend (after a warm shower, so it was nice and loose!) was my undoing.

Primary disc disease

There is another condition called Primary Disc Disease which is usually caused by a heavy blow or jarring of the spine. A blow to the buttocks will affect the lower lumbar discs. A blow to the head can affect discs in the neck. The disc itself doesn't prolapse, but the nucleus (the softest part in the centre) degrades. This is picked up as a dark disc on an MRI scan.

Pain from nerve roots

The nerve roots that emerge from between the vertebrae have a prolific supply of pain sensing equipment. If they are put under pressure from a bulging disc or swelling from the tissues around the facet joint, or from changes in the bony structures, then a lot of pain is felt.

Acute pain

If we are in an acute phase of pain, then exercise is not appropriate. At this stage we need rest and then mobilization of the joints. Acute pain needs rest and I do mean rest – not watching the TV or reading, but the deep healing rest of yoga nidra and prana nidra, plus meditation practices with movement of awareness in the frontal passage or along the spine with breath and/or mantra. Complementary therapies may be useful (osteopathy, physiotherapy or similar bodywork). Then exercise is phased in as therapy phases out. We can assist in this process with gentle loosening and massage of the affected areas using practices like 'pelvic rocking' and 'rocking and rolling'. If medication is used to dull the pain, then it is not advisable to do any body movements like these until the medication has worn off.

Chronic pain

Chronic pain can be constant or recurring. It can seem to move around or always come from one area. It can be hot, burning, stabbing, knife-like, or cold, aching or dragging. We need to discover if it is referred pain (visceral pain) which can come from the liver (usually experienced around the right shoulder blade) or menstrual (usually worse before or during the monthly bleed). If so, add the appropriate practices for the liver and endocrine system respectively, such as twisting and sideways bends for the liver and surya namaskara (salute to the sun) for endocrine.

Whether pain is acute or chronic, we also need practices to help us to attune to the mental and emotional stuff that always accompanies pain. When we have pain, we react on all levels of our being.

In physical pain there is:

• mental reaction: judgement (e.g. 'good' pain when we have a massage, 'bad' pain when we are incapacitated in some way), memory and comparison;
• emotional reaction – dislike, anger, annoyance;
• physical reaction to protect the area of 'bad' pain.

Similarly when we have emotional pain, e.g. grief or anger, we have mental and physical reactions.

Back pain is seen mostly as a reflection of deep subconscious or unconscious beliefs and conditioning. Writers like Louise Hay have even pinpointed how different parts of the back reflect different issues. This came home to me loud and clear when I met a man with multiple sclerosis which only affected his body below the 12th thoracic vertebra. His father was super critical of his actions. Criticism is seen as affecting the joint between the 12th thoracic and the 1st lumbar vertebra. I realized that if he was to gain any notable remission, first he would have to deal with his reactions to the criticism he received from his father.

Before examining the mental and emotional aspects of pain and how to deal with them through yoga we need to examine posture and the common patterns of imbalance. Regular practice of hatha yoga can help to correct poor patterns of posture that created the tiny injuries which led to back pain.

(Part 2 will look at postural imbalances and practices to manage back pain.)