What is lower back pain?
In our world, lower back pain is one of the most widespread musculoskeletal problems (Furlan, Clarke and Esmail),  which leads to substantial costs in health care. Musculoskeletal disorders are a heterogeneous class of disorders, which include degenerative disorders of osteoarthritis, inflammatory disorders like rheumatoid arthritis, and soft tissue disorders like lower back pain and fibromyalgia (Salaffi, De Angelis and Grassi).  Among these, lower back pain is one of the chief health issues affecting humans around the world (Andersson 1999) 
Lower back pain is described as the pain localized between the 12th rib and the inferior gluteal folds, which is nonspecific in 90% of the cases (Furlan, Brosseau and Imamura).  Researchers have not completely comprehended the etiology of lower back pain, which is quite complicated. Many of the acute lower back pain issues are a consequence of injury in the muscles, joints, ligaments, or discs. The body responds to injury through mobilizing an inflammatory response related to healing, and this inflammation creates acute pain. Based on the origin of the pain, various symptoms can be observed during lower back pain such as:
- Dull or achy pain, contained in the lower back
- Burning, stinging pain that extends from the lower back to the backward part of the thighs, and occasionally, towards the lower legs or feet; this may involve tingling sensation or numbness
- Tightness and spasms in muscles and in the lower back, hips, and pelvis
- Pain that increases after sitting or standing for long periods of time
- Trouble in standing up erect, walking, or changing from a sitting to standing position
Common categories of back pain include mechanical pain (pain that arises mainly from the muscles, joints, and ligaments, or from bones that are located in and around the spine) and radicular pain (it occurs if a spinal nerve root becomes inflamed or impinged). Mechanical pain is localized towards the lower back, buttocks, and occasionally, the upper parts of the legs, while radicular pain might follow a nerve root pattern or dermatome downwards to the buttock and/or leg (Peloza). 
This condition that is extremely prevalent is a major burden on individuals and healthcare organizations (Shelerud 1998).  Approximately 60–85% of the world’s population is affected by lower back pain at least once in their lifetime, with 10–20% accounting for the people whose issues develop into a chronic problem (Skovron 1992)(Waddell 1998).   In several nations such as Great Britain, Canada, Sweden, and The Netherlands, people are subject to disability from back pain, which is a major issue (Nachemson 1992).  Due to lower back pain, patients are limited in their day-to-day activities and might experience unsuitable neuromuscular adaptations for sustaining and/or carrying on different functions like walking, running, etc. (Hammil, Beazell and Hart 2008).  Clinical practice guidelines on the treatment of acute lower back pain were established and published by the US Department of Health and Human Services (currently referred to as the Agency for Healthcare Research and Quality) during the initial period of 1990s. These guidelines were categorized into three groups: 1) spinal disorders that are potentially critical, i.e., fractures, tumors, infections, and cauda equina syndrome), 2) sciatica or radiculopathy, and 3) symptoms related to back that are nonspecific. Sciatica means compression or irritation of the nerve root, while nonspecific symptoms related to back pain indicate the absence of a critical underlying spinal disorder or the involvement of nerve root. Nonspecific symptoms related to back and sciatica resolve without treatment in the majority of situations, i.e., patients can recover without needing medical care or nonsurgical therapy (Pradhan 2008). 
Complementary and alternative medicines (CAM) for back pain and other musculoskeletal issues/disorders
Mostly, the treatment of chronic musculoskeletal disorders is done through a biomedical model, which includes physical therapy or the prescriptive usage of pharmaceuticals (Koes, et al. 2001).  However, a system of therapies referred to as complementary and alternative medicine (CAM) therapies is widely used by patients with musculoskeletal conditions (P. Barnes, B. Bloom, R. Nahin). 
CAM represents a varied set of therapies, supplements, substances, methods, rituals, techniques, practices, systems etc., which are used by patients while making efforts to reduce health issues or for maintenance of health (Artus, P. Croft, M. Lewis).  Various kinds of CAM therapies include entire medical systems like homeopathy and naturopathy, practices founded on biology such as herbal products and dietary supplements, mind-body treatment such as prayer, meditation, and mental therapy, energy therapy such as therapeutic touch and Reiki, and medicine related to the body such as chiropractic care and massages (Gupta, et al. 2015).  The key motives behind the usage of these CAM therapies are reduction in pain and overcoming of functional limitations (Carlson and Krahn 2006), (Okoro, et al. 2012).   Patients use these therapies either in addition to biomedical treatment or as a preferred choice of treatment (M. Eisenberg, R. C. Kessler, et al).  It is believed that 38% of American citizens resort to some kind of CAM therapy to deal with their chronic pain from musculoskeletal conditions.
The effects of CAM on different kinds of musculoskeletal issues have been outlined as follows:
· Lower back pain: It has been proved through studies that acupuncture, spinal manipulation, and massage might be advantageous for chronic low back pain. In 2007, the American College of Physicians/American Pain Society published guidelines for clinical practice that advocate the abovementioned practices along with five other non-pharmocologic techniques for people having back pain when no progress is observed after medication and personal care. The other techniques advocated in the guidelines were cognitive-behavioral therapy, progressive relaxation, exercise therapy, yoga, and rigorous interdisciplinary rehabilitation. Studies on other CAM approaches, such as numerous herbal medicines and prolotherapy, which are used occasionally by patients for chronic lower back pain, have also demonstrated evidence for validating their usage for this disorder.
· Arthritis: Acupuncture, herbal therapies, glucosamine/chondroitin, tai chi, and mineral baths are some of the CAM therapies that researchers have investigated for relieving pain in osteoarthritis. Some therapies among these have further been investigated for rheumatoid arthritis. On the whole, even though favorable findings have been obtained in certain research works related to CAM practices for arthritis, largely, the evidence is inadequate or inconclusive. In an organized review paper related to acupuncture for osteoarthritis, it has been demonstrated that minor improvements in pain and function might be obtained through acupuncture. Nevertheless, in a major clinical study called GAIT (Glucosamine/chondroitin Arthritis Intervention Trial), glucosamine and chondroitin sulfate, the commonly used dietary supplements, were not successful in considerably alleviating pain of knee osteoarthritis for all participants, either on using individually or in a combined form, even though the combination assisted a subgroup of patients exhibiting moderate-to-severe pain. Some reviews have detected evidence that γ-linolenic acid (derived from evening primrose and some other plant oils) might assuage pain related to rheumatoid arthritis, though more studies are required in this area. Moreover, it has been revealed from research that relief from osteoarthritis pain might be obtained from dietary supplements like devil’s claw and avocado-soybean unsaponifiables.
· Neck pain: Manual approaches (mainly mobilizing or manipulating) and acupuncture for chronic pain in neck have demonstrated conclusive evidence in research works with regards to possible advantages. A review has stated that clinical regulations usually advocate using manual approaches for neck pain, though no general consensus exists regarding the status of these approaches. 
A type of CAM that has become increasingly prevalent among patients suffering from musculoskeletal issues is yoga (P. Barnes, B. Bloom, R. Nahin, B. Saper, and D. M. Eisenberg, R. B. Davis, L. Culpepper, R. S. Phillips). [13, 20] Yoga consists of physical, breathing, and relaxation methods, and has been considered to offer musculoskeletal as well as psychosocial advantages, which are presently not granted by the prescriptive treatment of musculoskeletal disorders (Evans, J. C. Tsao, et al). 
As per the literature, studies have proved that in case of fibromyalgia and mild-to-moderate lower back pain, yogic techniques considerably improved functional outcomes in comparison with passive control interventions. Additionally, according to an early research work on the effect of yoga on osteoarthritis, an intervention based on Iyengar yoga for eight weeks improved finger range of motion in a yoga group in comparison with a regular care group.
Overall, evidence suggests that yoga is an acceptable and safe intervention, which may result in clinically relevant improvements in pain and functional outcomes associated with a range of musculoskeletal conditions. A future analysis of outcomes which take into account the amount of yoga received by participants may provide insight into any putative duration or dosage effects of yoga interventions for musculoskeletal conditions (L. Ward, et al). 
Considerations for yoga in patients with back pain
Fundamentally, yoga is still a method of physical movement, and like all other exercises, there is a possibility of injury, particularly involving the back. As stated by Dr. Lauren Elson, an instructor in physical medicine and rehabilitation at Harvard Medical School, the major issues often occur because people don’t adhere to appropriate guidelines while doing yoga, and they rapidly start doing yoga poses instead of gradually “lengthening” into them. This leads to a higher probability of injury.
In yoga, muscles should be used to initially form a firm basis for movement, and consequently, an appropriate form must be adhered to that gradually stretches and lengthens the body. For instance, one should avoid rotating as fast and far as possible while performing a seated spinal twist pose or ardha matsyendrasana, which is known to be extremely beneficial for lower back pain. Dr. Elson further explains “Instead, you should first activate your core muscles and feel as though the spine is lengthening. Then, twist slowly until you feel resistance, and hold for as long as it’s comfortable.”
Patients should definitely discuss with their doctor regarding whether they should commence yoga practice while suffering from lower back pain. As per Dr. Elson, yoga should be avoided while suffering from particular back issues like a spinal fracture or a herniated disc. After the patients obtain a doctor’s approval, they should inform the yoga instructor in advance regarding their specific pain and limitations, which can help in safeguarding their back from injuries. Consequently, the instructor can provide protective adjustments to particular poses or assist in guiding the patient while carrying out a pose to make sure that he/she performs it perfectly without applying stress on the back. An alternate choice is to find a yoga studio or community center that provides classes that are specially intended for alleviating back pain.
It should be noted that the bending, stretching, and twisting movements of yogic postures are regularly required by the lower back for improvement. As Dr. Elson states, “By mindfully practicing yoga, people can safely stretch and strengthen tight and aching back muscles.”
Tips/Techniques to protect the back while doing yoga
Patients should always take precautions while performing yoga for back pain. Some tips for protecting your back while doing yoga are included below.
- Twisting and extending simultaneously can compress intervertebral joints and should be avoided.
- Use props such as bolsters and blocks for extra support.
- If the person is not able to touch his/her toes while performing yoga, he/she can hold a yoga belt in his/her hands and loop it around his/her feet.
- Forward bends should be performed from a seated position and the stomach should be engaged as the body is lifted upright.
- Any move that provides discomfort should be eased or discontinued. 
Additionally, let’s discuss some do’s and don’ts of yogic practice for individuals with back pain:
· Don’t lose your normal lumbar curve. The back can be affected by slumping, or rounding the spine, due to working for lengthy periods in an office chair that leads to incorrect posture. While performing most yoga poses as well as all through the day, whether sitting or standing, conserving the natural inner curve in the lower back is necessary. The head’s back should be in line with the back of the pelvis, and the shoulders should be held broad and stacked right above the hips. A completely flat back is not recommended although the yoga instructor might indicate a “flat back (which is suggested to avert loss of the normal spinal curve by overarching or rounding the back),” The original curves of the spine, i.e., a slender inward curve of the lumbar spine (lower part of the back), a minor outward curve of the thoracic spine (middle/upper back), and a minor inward curve of the cervical spine (neck), are necessary for absorbing shock and for maintaining ideal health of the spine.
· Do practice sitting and standing positions that are healthier for assistance in strengthening the back. Core support should be used during sitting or standing, with a minor lift of the lower abdominals and pelvic floor.
· Don’t let the feet turn outwards while walking or standing. The feet being externally rotated is both an outcome and a source of shortening of the piriformis in case of several individuals. If this deep hip rotator becomes tight, the psoas (which extends from the lumbar spine till the uppermost part of the thigh) also tends to get tight, which may lead to low back pain.
· Do maintain the feet in a parallel position. When the toes incline towards turning out, the heels should be sufficiently moved outwards such that they are towards the back of the toes. In each foot, the second toes should be relatively parallel with each other, and the knees should be in line with the midpoint of the foot. This position should be maintained while sitting, standing, and walking.
· Don’t round up after a standing forward fold using straight legs. The discs of the anterior spine can be compressed through this act, which can increase the pain in the back.
· Do get up after a forward fold with slightly bent knees, and utilize core support while lifting the torso.
· Don’t neglect core strength. In case of yoga, greater emphasis is placed on stretch instead of strength. Stretching is significant in relieving tightness in back muscles, and postures that are linked to a perfect back stretch like marjaryasana, balasana, ananda bala, and supine twists provide a positive and pleasant feeling. However, these postures fail to contribute extensively to forming core strength, which is significant in case of health for the back. The support towards the front should be stable for strengthening the backward portion of a structure. Therefore, postures that involve strength of abdomen and back are necessary for back health. Strengthening of the muscles in the abdomen and back assists a more efficient alignment of the spine. These postures are recommended for practice in a yoga class that is focused on back health (B. Spindler). 
Some other tips for avoiding lower back pain:
· Care should be taken while sitting for long hours on the ground. Several times, this can lead to pressure on the lower back and hips.
· Bending forward in an aggressive manner initially in the morning is not recommended if the discs are swollen and susceptible to compression.
· Sitting cross-legged should be avoided for long hours. 
Efficacy of Yoga in Back Pain
Chronic pain distresses nearly 100 million individuals in the United States, resulting in $635 billion in annual costs, including specific medical costs and lost productivity (Simon 2).  Low back pain (LBP) affects 70% of the population at some point in their life, with recurrence rates as high as 85% (Hoy et al. 2028).  With such a high lifetime frequency, LBP is a likely source of various chronic symptoms. Chronic LBP can interfere with daily activities by limiting mobility, impairing work obligations, and severely influencing self-care, in addition to generating overall discomfort (Crown 114).  Despite the fact that many patients have surgeries to cure or repair patho-anatomy for LBP, many endure chronic symptoms, which can be caused by a variety of biologic and behavioral factor (Deyo 569).  As a result, chronic LBP comprises multidimensional problem involving psychological, physical, and social factors (Rodriguez-Raecke et al. e54475).  Furthermore, chronic LBP can evolve beyond chronic symptoms to a situation in which the central nervous system’s functional and morphological abnormalities are irreversible (Jain 0).  These functional deficiencies might also have negative psychological and emotional effects (Sullivan et al. 5).  Despite a wide range of therapeutic choices, persistent LBP can be difficult and expensive to manage, and 17% of adults in the U.S. seek relief from their back pain through complementary and alternative medicine (CAM) (Gou et al.1029). 
Yoga’s popularity has exploded during the last few years. According to global advances 2021, it is considered as one of those CAM therapies which integrate the particular human spirit with divine spirit, or the True Self (Kebede et al.).  Further, the Centers for Disease Control and Prevention’s (CDC) National Health Interview Survey results suggest an increase in the use of CAM treatments (M.A., and Barbara Bloom 258.  CAM therapies are most commonly utilized to treat musculoskeletal problems, such as back pain and, to a lesser extent, neck discomfort (Currie and Wang 1275).  Yoga means “yoking” i.e “coming together” in reference to a harmonious relationship of mind–body as a medicine (His Divine Grace A.C. and Bhaktivedanta Swami Prabhupada).  It is an eight-limbed discipline that incorporates physical, mental, and spiritual health, according to traditional definitions. Postural alignment (“asanas”), breathing, concentration, focus, contemplation, absorption/stillness and meditation are all common features of modern Hatha yoga (Shannahoff-Khalsa 91).  A typical Hatha yoga class consists of a group of people who are taught by an instructor during a 60–90 minute session. The instructor instructs on proper posture, breathing, and concentration. They frequently promote positive self-esteem (Stiles).  Yoga refers to a set of physical and spiritual activities that originated in ancient India and are used to create profound meditation states and gain deeper harmony with the divine or inner self. It has been proposed that yoga achieves peace, inner strength, emotional and physical equilibrium by combining asanas (Hatha yoga postures) with breathing patterns (pranayama), meditation (dhyana) that are primarily focused on isometric muscle contractions (Posadzki and Parekh 66).  Hatha yoga as mild postures for relaxation, as well as Iyengar yoga for breathing methods and physical postures, are commonly used in trials of yoga for chronic pain therapy (K. Williams et al. 2066). 
Yoga offers a wide range of clinical and nonclinical uses. For instance, LBP is one of the most frequent musculoskeletal issues in today’s culture, and it costs a lot of money to treat (Gou et al. 1029; Kosinski et al. 6). [33, 42] Patients with LBP often notice how back pain often hampers their daily activities. Patients sometimes may develop improper neuromuscular responses in order to maintain and/or preserve functions such as walking, jogging, and other activities (Burström et al.612; Furlan E155). [43, 44] Yoga may lower LBP, however the mechanisms by which this is accomplished are less researched. Some contributing factors include a rise in tissue flexibility and oxidation, as well as a calming effect and the release of enkephalins or endorphins in the lower back (Pilkington et al.; K Nespor). [45,46] The literature on yogic practices for pain treatment has not yet been critically assessed, to our knowledge. However, when documented, the adverse events associated with doing yoga to treat musculoskeletal disorders were minor and not life-threatening. This is mostly due to the degree of intricacy and multidimensionality of forces visible in yoga activities (Seidler et al. 322; Furlan et al. 1669). [44, 47] Some authors claimed that yoga activities have no negative consequences when practiced correctly, however the general and comprehensive indications and contraindications of various yoga exercises must be carefully followed.
Postures of Yoga and Pain Relief Mechanism
Back discomfort is frequently caused by strain such as muscle sprains, ligament sprains, and carrying weight incorrectly, all resulting in an unexpected and awkward action. This sprain can cause LBP and the Yoga Asanas/postures are helpful in relieving this pain. Some of the common postures/asanas are Setu Bandha Sarvangasana, Balasana, Bhujangasana, Adho mukha svanasana, Marjarasan, Uttanasana, Parshvakonasana, Savasana (K. A. Williams et al. 107).  These asanas relieve the back pain with different mechanisms for stretching and relieves the fascia of the muscle, hence decreasing the pain. For instance, Setu Bandhasana stretches the spine and reduces the back soreness. Balasana relieves lower back tension by stretching the spine, which decompresses it and relieves pain. By engaging your back muscles, Bhujangasana extends your core and abdominal muscles. Adho Mukha Svanasana treats back pain by resolving body imbalances and strengthens the back. The combination of Marjaryasana and Bitilasana relaxes the back muscles. Similarly, all the mentioned asanas combined aid the process of relieving the back ache (Petering and Webb 550; Telles et al. 69). [49,50]
Few of the studies have examined how yoga might help people with back ache. For example, Lee et al and Sherman et al. studied various mediators such as brain derived neurotrophic factor (BDNF), serotonin, dehydroepiandrosterone (DHEA), cortisol to understand the mechanism of yoga therapy for reliving back pain (Sherman, Wellman, et al.; Lee et al.). [51, 52] In addition, Sherman et al. also looked into psychological aspects that could be mediating yoga’s effect on back pain. These factors involved stress, psychological discomfort, cognitive appraisals, fear avoidance, positive states of mind, neuroendocrine function and physical activity. DHEA and cortisol levels in saliva samples were used to gauge neuroendocrine function. The purpose was to see which metric in the yoga, stretching, and self-care groups had the greatest impact on back-related dysfunction. The most important factors that contributed to yoga’s benefit were self-efficacy and hours of back exercise. A minor amount of sleep disruption was also a factor. Cortisol and DHEA levels had little influence (Sherman, Wellman, et al.). 
Further, Lee et al. examined the effects of yoga in premenopausal women with persistent low back pain. The yoga group experienced less pain, more BDNF, and the same amount of serotonin. In contrast to the untreated control group where, pain was higher, BDNF was lower, and serotonin was lower. This suggests that the positive effects of yoga are linked to increased BDNF levels in the blood and stable serotonin levels. The study was limited to gender and sample size (Lee et al.). 
Effect of Yoga on Back Pain
By now you know that yoga is a CAM practice that includes a number of disciplines such as asanas, pranayama, and meditation. According to 2018 report, yoga’s popularity has consistently grown over the last decade, with around 28% of adults in the U.S preferring yoga (U.S, 2018).  The number of modern yoga practitioners in the U. S. is estimated to be around 28.75 million people. According to published research, yoga helps ease back ache and minimize physical and functional disability caused by it. However, due to insufficient statistical power and variance in the outcome measures utilized between investigations, these studies have produced mixed results (Swain and McGwin 11).  The objective of this study was to investigate the impact of yoga on impairment associated with chronic LBP diseases using a robust meta-analysis and systematic review (Crow et al.3). 
In a small scale study (controlled randomized experiment), the yoga group demonstrated advances in balance and flexibility, as well as decreased depression and functional disability (Mary Lou Galantino 49).  Similarly, in a 16-week controlled randomized experiment, patients with LBP treated with Iyengar yoga therapy were compared to a control group to validate the effectiveness of yoga. The findings provide evidence that the yoga practitioners reported less ache and functional impairment than the control group (K. A. Williams et al. 107).  Further, Williams et al. again attempted a 24-week research and proved significantly decreased functional impairment, pain severity, and depression in the yoga practitioners (K. Williams et al. 2066)]. 
An intense seven-day residential yoga programmed for patients with LBP was completed by 80 patients with LBP (Tekur, Chametcha, et al. 637).  Yoga’s impact on disability, quality of life and flexibility were investigated. The intervention group meditated, did yoga exercises, chanted, and attended lectures on a daily basis. The control group had a regular schedule that included exercise, educational lectures, non-yogic breathing exercises, and watching nature shows. This control differs from the standard controls utilized in previous studies. Between the two groups, there was a significant difference in disability, with the yoga group benefiting more than the control. The yoga members improved their flexibility and pain levels more than the control (Tekur, Singphow, et al. 10). 
Another study enrolled 53 persons who had previously participated in either physical therapy or a yoga intervention to treat LBP, outcome predictors were investigated. At 6 weeks, there were no substantial variations in disability. In both the groups, back pain was found to be the key indicators of health status, pain and disability. The back pain scale was used to examine a person’s belief in their ability to affect results by their individual activities. The criteria of self-selection unfairness in this study is a serious drawback, as the participants were previously enrolled into the physical therapy or yoga groups before the investigation (Evans et al.11).  Likewise, two large randomized trials have looked at the effects of yoga on physical functioning. The comparative study was carried out by Tilbrook et al. for 12-week comparing adults following yoga programmed (long-term effectiveness) versus a back pain instruction booklet. At 3, 6, and 12 months, the yoga members reported a significantly superior back function than the group following booklet (Tilbrook et al. 569; Cox et al.187). [60, 61] For individuals with LBP, Sherman et al. compared yoga routine to self-care instruction booklet method. With time, all of the cohorts’ function and symptoms improved. When compared to the self-care group, the yoga and stretching groups achieved equal outcomes (Sherman, Cherkin, Wellman, et al. 2019).  The authors concluded that the physical benefits of yoga outweigh the mental benefits.
Further, the 8-week pilot study was carried out with adult women suffering from musculoskeletal disorders such as osteoarthritis with LBP looked at the benefits of yoga on balance and gait. When compared to pre-study levels, the subjects’ balance and gait characteristics improved statistically. (Ülger and Yaĝllulger 13). 
Yoga has been shown to be useful in relieving pain related to chronic LBP in a number of studies. The pain-related anxieties of movement and pain beliefs were all assessed by Williams et al as the study compared the educational control group and the yoga intervention. The results found a two-fold reduction in pain and pain medication use (K. A. Williams et al.107).  There was no substantial difference in movement anxieties or pain attitudes, possibly because the study lacked statistical power to detect these differences. Williams et al. went on to show that a 24-week Iyengar yoga programme can help people with chronic LBP. Individuals in the yoga group improved their pain intensity more than those in the control group (K. Williams et al. 2066). 
The effect of yoga on back pain in low-income, racially diverse people was investigated by Saper et al. Following the 12-week treatment, respondents’ average LBP intensity for the preceding week was drastically reduced from 7 to 5 regardless of whether they attended once or multiple times yoga classes (Saper et al.).  Further, due to the complexities of pain, Sherman et al. noted pain “bothersomeness” rather than pain severity. Subjects reported their back pain on an 11-point scale ranging from “not at all” to “extremely” troublesome during the preceding week in accordance to a 3-month yoga, exercise, or book education intervention (Sherman, Cherkin, Wellman, et al. 2019).  All of the therapies were beneficial, but the exercise and yoga groups showed the most improvement.
The “bothersomeness” of back pain was investigated in people who had previously had either a physical therapy or a yoga intervention. Both interventions were effective, and after 6 weeks of treatment, there were no substantial differences between the physical therapy and yoga groups. However, the yoga group’s baseline structures were such that they had less back ache and functional disability to begin with. In participants with nonspecific chronic low back pain, a randomized controlled trial looked at the effects of Iyengar yoga on pain severity and overall health-related quality of life. The researchers assessed yoga therapy to traditional exercise therapy over a six-month period (GS et al. 48).  Both programs had a considerable impact, but the yoga intervention had the bigger influence.
To date, the scientific literature on yoga’s influence on psychological health has not been fully described. In a study of veterans with back pain, Groessl et al. looked at the effects of yoga on psychological conditions like mental depression and effect on quality of life (Groessl, Weingart, Aschbacher, et al. 1123).  They discovered considerable reductions in depression, as well as a trend toward significant gains in the SF-12’s Mental Health Scale. The amount of home practice reported by the individuals tended to correlate with the improvement in depression. In participants with chronic LBP, the effects of Iyengar yoga on depression were evaluated. Subjects in the yoga group improved more than those in the control group in terms of depression. The yoga group was given substantial attention than the control group, which was one of the study’s limitations. The lack of controls for physical activity between the groups was another limitation (Groessl, Weingart, Johnson, et al. 832).  Further, Tekur et al. compared yoga group to the controls and discovered that the yoga group improved much more on the psychological state of their mind and the quality of life. This residential study, however, included more features than the standard Hatha or Iyengar yoga interventions (e.g., 8 hours of interactive talks, chanting, and meditation sessions per day (Tekur, Chametcha, et al. 637).  In addition, this was a one-week follow-up study. Similarly, with the mental health condition, one randomized controlled experiment (Tilbrook et al. 569) and an associated pilot research (Cox et al.187) compared yoga to “usual care.” [60, 61] The pilot study indicated no significant differences, however the sample size was small (n = 20). The power of their follow-up study was sufficient. At the 3-, 6-, and 12-month examinations, they found no substantial differences in psychological functions or mental health (although the 3 and 6 month assessments demonstrated a trend towards improvement). According to these reports, yoga is beneficial in lowering ache and functional disability, as well as increasing physical and psychological function.
Safety Data of Yoga for back pain
LBP is a physical disease that has a high recurrence rate and a high rate of partial recovery. As a result, it’s not uncommon to see some negative outcomes while investigating patients with back discomfort (Kamper et al. 9).  Yoga positions, on the other hand, do not appear to pose a significant risk to healthy persons or patients with back pain. In one study, one adverse event was documented among 30 patients who were randomly assigned to yoga. During the trial, a participant had symptoms of osteoarthritis and was diagnosed with a ruptured disc (K. A. Williams et al.107).  The Institutional Review Board decided that the adverse event was unrelated to the yoga postures after conducting a medical review. In the yoga versus exercise experiment, there were no significant adverse effects recorded among the 101 participants (Sherman, Cherkin, Erro, et al. 849).  One yoga student dropped out owing to migraine, and another exerciser hurt her back and received help from a chiropractor. Sherman et al. identified an equivalent incidence of moderate adverse effects (mainly briefly increased LBP) in both the yoga and the standard stretching interventions. A significant occurrence occurred once in the 87 yoga class participants, a herniated disc. One person in the control group with self-care treatment experienced severe pain. Despite all of these negative events, the stretching and yoga groups had reasonably better results overall.  Finally, safety data from the most latest and significant trials demonstrate a 10%–15% occurrence of substantially improved LBP discomfort, with two cases of herniated disc discovered. There appear to be certain concerns linked with yoga. However, the majority of individuals believe to gain large benefits due to yoga interventions with little or no negative effects (Sherman, Cherkin, Wellman, et al. 2019).  Overall, yoga appears to be a more well established intervention as the health sector transitions from treating acute illnesses to treating chronic diseases, and healthcare providers pursue to establish preventive measures to combat the enduring diseases that plague modern society. Since yoga is a reflective activity, it may be useful for military veterans who are dealing with the long-term effects of wartime stress.
Yoga appears to be just as helpful as other non-pharmacologic therapy at reducing back pain’s functional impairment. When compared to conventional treatments/therapies, it proves to be more successful in reducing the recurrence of LBP or dipping the pain severity. Yoga may help with depression and other psychological co-morbidities by maintaining serotonin or BDNF levels in the blood. Yoga demonstrates to be a safe way to treat persistent low back pain.
1. D. Furlan, J. Clarke, R. Esmail, S. Sinclair, E. Irvin, C. Bombardier, A critical review of reviews on the treatment of chronic low back pain, Spine 26 (2001) E155-E162. https://pubmed.ncbi.nlm.nih.gov/11295917/
2. F. Salaffi, R. De Angelis, W. Grassi, Prevalence of musculoskeletal conditions in an Italian polulation sample: Results of a regional community-based study. I. The MAPPING study, Clin. Exp. Rheumat. 23 (2005) 819-828. https://pubmed.ncbi.nlm.nih.gov/16396700/
3. G. B. Andersson, Epidemiological features of chronic low-back pain, Lancet 354 (1999) 581-585. https://pubmed.ncbi.nlm.nih.gov/10470716/
4. Furlan, L. Brosseau, M. Imamura, E. Irvin, Massage for low-back pain: a systematic review within the framework of the Cochrane Collaboration Back Review Group, Spine 27 (2002) 1896-1910. https://pubmed.ncbi.nlm.nih.gov/12221356/
5. J. Peloza, Lower back pain symptoms, diagnosis, and treatment, www.spine-health.com, 20 April 2017 https://www.spine-health.com/conditions/lower-back-pain/lower-back-pain-symptoms-diagnosis-and-treatment (accessed 29 November 2021).
6. R. Shelerud, Epidemiology of occupational low back pain, Occup. Med. 13 (1998) 1-22. https://pubmed.ncbi.nlm.nih.gov/16963373/
7. M. L. Skovron, Epidemiology of low back pain, Baillière. Clin. Rheum. 6 (1992) 559-573. https://www.sciencedirect.com/science/article/abs/pii/S095035790580127X
8. The back pain revolution: G. Waddell: Amazon.com: https://www.amazon.in/Back-Pain-Revolution-Gordon Waddell/dp/0443060398/ref=tmm_hrd_swatch_0?_encoding=UTF8&qid=&sr= (accessed 29 November 2021).
9. L. Nachemson, Newest knowledge of low back pain: a critical look, Clin. Orthop. Relat. Res. 279 (1992) 8-20. https://pubmed.ncbi.nlm.nih.gov/1534725/
10. R. R. Hammil, J. R. Beazell, J. M. Hart, Neuromuscular consequences of low back pain and core dysfunction, Clin. Sports Med. 27 (2008) 449-462. https://pubmed.ncbi.nlm.nih.gov/18503877/
11. B. Pradhan, Evidence-informed management of chronic low back pain with watchful waiting, Spine J. 8 (2008) 253-257. https://pubmed.ncbi.nlm.nih.gov/18164473/
12. W. Koes, M. W. Van Tulder, R. Ostelo, A. Kim Burton, G. Waddell, Clinical guidelines for the management of low back pain: An international comparison, Spine 26 (2001) 2504-2514. https://pubmed.ncbi.nlm.nih.gov/11707719/
13. P. Barnes, B. Bloom, R. Nahin, Complementary and alternative medicine use among adults and children: United States, 2007, Natl Health Stat Report (2008) 1-23. https://pubmed.ncbi.nlm.nih.gov/19361005/
14. Artus, P. Croft, M. Lewis, The use of CAM and conventional treatments among primary care consulters with chronic muskuloskeletal pain, BMC Fam. Pract. 8 (2007) 1-14. https://pubmed.ncbi.nlm.nih.gov/17480212/
15. Gupta, M. Devaki, N. Dommaraju, K. T. Srinivas, A. A. Patil, R. K. Momin, A. Jain, R. K. Gupta, Musculoskeletal pain management among dentists, Holist. Nurs. Pract. 29 (2015) 385-390. https://pubmed.ncbi.nlm.nih.gov/26067590/
16. M. J. Carlson, G. Krahn, Use of complementary and alternative medicine practitioners by people with physical disabilities: Estimates from a National US Survey, Disabil. Rehabil. 28 (2006) 505-513. https://pubmed.ncbi.nlm.nih.gov/16513583/
17. C. A. Okoro, G. Zhao, C. Li, L. S. Balluz, Use of complementary and alternative medicine among US adults with and without functional limitations, Disabil. Rehabil. 34 (2011) 128-135. https://www.tandfonline.com/doi/abs/10.3109/09638288.2011.591887?journalCode=idre20.
18. M. Eisenberg, R. C. Kessler, M. I. Van Rompay, T. J. Kaptchuk, S. A. Wilkey, S. Appel, R. B. Davis, Perceptions about complementary therapies relative to conventional therapies among adults who use both: Results from a national survey, Ann. Intern. Med. 135 (2001) 344-351. https://pubmed.ncbi.nlm.nih.gov/11529698/
19. Chronic Pain: Study of Complementary and Alternative Treatments, www.practicalpainmanagement.com, 15 April 2015 https://www.practicalpainmanagement.com/treatments/complementary/chronic-pain-study-complementary-alternative-treatments.
20. B. Saper, D. M. Eisenberg, R. B. Davis, L. Culpepper, R. S. Phillips, Prevalence and patterns of adult yoga use in the United States: Results of a national survey, Altern. Ther. Health Med. 10 (2004) 44-49. https://pubmed.ncbi.nlm.nih.gov/15055093/
21. Evans, J. C. Tsao, B. Sternlieb, L. Zeltzer, Using the biopsychosocial model to understand the health benefits of yoga, J. Complement. Integr. 6 (2009). https://www.degruyter.com/document/doi/10.2202/1553-3840.1183/html
22. L. Ward, S. Stebbings, D. Cherkin, G. D. Baxter, Yoga for functional ability, pain and psychosocial outcomes in musculoskeletal conditions: A systematic review and meta-analysis, Musculoskelet. Care 11 (2013) 203-217. https://pubmed.ncbi.nlm.nih.gov/23300142/
23. The safe way to do yoga for back pain, www.health.harvard.edu, 11 April 2021 https://www.health.harvard.edu/staying-healthy/the-safe-way-to-do-yoga-for-back-pain
24. B. Spindler, Yoga for lower back pain: Learn the Do’s and Don’ts, n.d. www.yogainternational.com., https://yogainternational.com/article/view/yoga-for-lower-back-pain-learn-the-dos-and-donts.
25. 5 Ways To Protect Your Lower Back During Yoga, www.kinfolkwellness.com.au, 8 November 2016 http://www.kinfolkwellness.com.au/blog/5-ways-to-prevent-lower-back-pain-during-yoga.
26. L.S. Simon, RELIEVING PAIN IN AMERICA: A BLUEPRINT FOR TRANSFORMING PREVENTION, CARE, EDUCATION, AND RESEARCH
27. D. Hoy, C. Bain, G. Williams, L. March, P. Brooks, F. Blyth, A. Woolf, T. Vos, R. Buchbinder, A systematic review of the global prevalence of low back pain, Arthritis Rheum. 64 (2012) 2028–2037. https://doi.org/10.1002/ART.34347
28. S. Crown, Psychological aspects of low back pain, Rheumatol. Rehabil. 17 (1978) 114–124. https://doi.org/10.1093/RHEUMATOLOGY/17.2.114
29. R.A. Deyo, S.F. Dworkin, D. Amtmann, G. Andersson, D. Borenstein, E. Carragee, J. Carrino, R. Chou, K. Cook, A. Delitto, C. Goertz, P. Khalsa, J. Loeser, S. MacKey, J. Panagis, J. Rainville, T. Tosteson, D. Turk, M. Von Korff, D.K. Weiner, Report of the NIH Task Force on Research Standards for Chronic Low Back Pain, J. Pain. 15 (2014) 569–585. https://doi.org/10.1016/J.JPAIN.2014.03.005
30. R. Rodriguez-Raecke, A. Niemeier, K. Ihle, W. Ruether, A. May, Structural Brain Changes in Chronic Pain Reflect Probably Neither Damage Nor Atrophy, PLoS One. 8 (2013) e54475. https://doi.org/10.1371/JOURNAL.PONE.0054475
31. R. Jain, Pain and the Brain: Lower Back Pain, J. Clin. Psychiatry. 70 (2009). https://doi.org/10.4088/JCP.7131CC7C.E41
32. M.J.L. Sullivan, K. Reesor, S. Mikail, R. Fisher, The treatment of depression in chronic low back pain: review and recommendations, Pain. 50 (1992) 5–13. https://doi.org/10.1016/0304-3959(92)90107-M
33. H.R. Gou, S. Tanaka, W.E. Halperin, L.L. Cameron, Back pain prevalence in US industry and estimates of lost workdays., Https://Doi.Org/10.2105/AJPH.89.7.1029. 89 (2011) 1029–1035. https://doi.org/10.2105/AJPH.89.7.1029
34. E.B. Kebede, J. Tan, S. Iftikhar, H.S. Abu Lebdeh, M.K. Duggirala, A.K. Ghosh, I.T. Croghan, S.M. Jenkins, S. Mahapatra, B.A. Bauer, D.L. Wahner-Roedler, Complementary and Alternative Medicine Use by Patients From the Gulf Region Seen in the International Practice of a Tertiary Care Medical Center, Glob. Adv. Heal. Med. 10 (2021). https://doi.org/10.1177/21649561211010129
35. P.M.B. M.A., and Barbara Bloom, Complementary and Alternative Medicine Use Among Adults and Children: United States, 2007, Natl. Cent. Heal. Stat. Reports. (2008) 258–262. https://pubmed.ncbi.nlm.nih.gov/19361005/
36. S.R. Currie, J. Wang, More data on major depression as an antecedent risk factor for first onset of chronic back pain, Psychol. Med. 35 (2005) 1275–1282. https://doi.org/10.1017/S0033291705004952
37. Bhagavad-Gita as It is: With Original Sanskrit Text, Roman Transliteration, English Equivalents, Translation, and Elaborate Purports: Prabhupada, His Divine Grace A. C. Bhaktivedanta Swami: Amazon.com: Books, (n.d.). https://www.amazon.com/Bhagavad-Gita-Transliteration-Equivalents-Translation-Elaborate/dp/B000JWPL94 (accessed November 26, 2021)
38. D.S. Shannahoff-Khalsa, An introduction to Kundalini yoga meditation techniques that are specific for the treatment of psychiatric disorders, J. Altern. Complement. Med. 10 (2004) 91–101. https://doi.org/10.1089/107555304322849011
39. M. Stiles, Structural yoga therapy : adapting to the individual, (2000) 343. https://www.amazon.in/Structural-Yoga-Therapy-Adapting-Individual/dp/1578631777
40. P. Posadzki, S. Parekh, Yoga and physiotherapy: a speculative review and conceptual synthesis, Chin. J. Integr. Med. 15 (2009) 66–72. https://doi.org/10.1007/S11655-009-0066-0
41. K. Williams, C. Abildso, L. Steinberg, E. Doyle, B. Epstein, D. Smith, G. Hobbs, R. Gross, G. Kelley, L. Cooper, Evaluation of the effectiveness and efficacy of iyengar yoga therapy on chronic low back pain, Spine (Phila. Pa. 1976). 34 (2009) 2066–2076. https://doi.org/10.1097/BRS.0B013E3181B315CC
42. M.R. Kosinski, J.R. Schei, S.M. Vallow, S. Ascher, C. Harte, R. Shikiar, L. Frank, M.K. Margolis, G. Vorsanger, An observational study of health-related quality of life and pain outcomes in chronic low back pain patients treated with fentanyl transdermal system, Http://Dx.Doi.Org/10.1185/030079905X46377. 21 (2005) 849–862. https://doi.org/10.1185/030079905X46377
43. K. Burström, M. Johannesson, F. Diderichsen, Swedish population health-related quality of life results using the EQ-5D, Qual. Life Res. 2001 107. 10 (2001) 621–635. https://doi.org/10.1023/A:1013171831202
44. A.D. Furlan, M. Imamura, T. Dryden, E. Irvin, Massage for low back pain: An updated systematic review within the framework of the cochrane back review group, Spine (Phila. Pa. 1976). 34 (2009) 1669–1684. https://doi.org/10.1097/BRS.0B013E3181AD7BD6
45. K. Pilkington, G. Kirkwood, H. Rampes, J. Richardson, Yoga for depression: the research evidence, J. Affect. Disord. 89 (2005) 13–24. https://doi.org/10.1016/J.JAD.2005.08.013
46. K Nespor, Psychosomatics of back pain and the use of yoga – PubMed, (1989). https://pubmed.ncbi.nlm.nih.gov/2532183/ (accessed November 26, 2021)
47. A. Seidler, F. Liebers, U. Latza, Prävention von Low-Back-Pain im beruflichen Kontext, Bundesgesundheitsblatt – Gesundheitsforsch. – Gesundheitsschutz 2008 513. 51 (2008) 322–333. https://doi.org/10.1007/S00103-008-0463-3
48. K.A. Williams, J. Petronis, D. Smith, D. Goodrich, J. Wu, N. Ravi, E.J. Doyle, R.G. Juckett, M.M. Kolar, R. Gross, L. Steinberg, Effect of Iyengar yoga therapy for chronic low back pain, Pain. 115 (2005) 107–117. https://doi.org/10.1016/j.pain.2005.02.016
49. R.C. Petering, C. Webb, Treatment options for low back pain in athletes, Sports Health. 3 (2011) 550–555. https://doi.org/10.1177/1941738111416446
50. S. Telles, N. Sayal, C. Nacht, A. Chopra, K. Patel, A. Wnuk, P. Dalvi, K. Bhatia, G. Miranpuri, A. Anand, Yoga: Can It Be Integrated with Treatment of Neuropathic Pain, Integr. Med. Int. 4 (2017) 69–84. https://doi.org/10.1159/000463385
51. K.J. Sherman, R.D. Wellman, A.J. Cook, D.C. Cherkin, R.M. Ceballos, Mediators of yoga and stretching for chronic low back pain, Evidence-Based Complement. Altern. Med. 2013 (2013). https://doi.org/10.1155/2013/130818
52. M. Lee, W. Moon, J. Kim, Effect of yoga on pain, brain-derived neurotrophic factor, and serotonin in premenopausal women with chronic low back pain, Evidence-Based Complement. Altern. Med. 2014 (2014). https://doi.org/10.1155/2014/203173
53. Yoga: number of participants U.S. 2018 | Statista, (n.d.). https://www.statista.com/statistics/191625/participants-in-yoga-in-the-us-since-2008/ (accessed November 26, 2021)
54. T.A. Swain, G. McGwin, Yoga-Related Injuries in the United States From 2001 to 2014, Orthop. J. Sport. Med. 4 (2016). https://doi.org/10.1177/2325967116671703
55. E.M. Crow, E. Jeannot, A. Trewhela, Effectiveness of Iyengar yoga in treating spinal (back and neck) pain: A systematic review, Int. J. Yoga. 8 (2015) 3. https://doi.org/10.4103/0973-6131.146046
56. T.M.B. Mary Lou Galantino 1, The impact of modified Hatha yoga on chronic low back pain: a pilot study – PubMed, (2004). https://pubmed.ncbi.nlm.nih.gov/15055095/ (accessed November 26, 2021)
57. P. Tekur, S. Chametcha, R. Hongasandra, N. Raghuram, Effect of yoga on quality of life of CLBP patients: A randomized control study, Int. J. Yoga. 3 (2010) 10. https://doi.org/10.4103/0973-6131.66773
58. P. Tekur, C. Singphow, H.R. Nagendra, N. Raghuram, Effect of Short-Term Intensive Yoga Program on Pain, Functional Disability and Spinal Flexibility in Chronic Low Back Pain: A Randomized Control Study, Https://Home.Liebertpub.Com/Acm. 14 (2008) 637–644. https://doi.org/10.1089/ACM.2007.0815
59. D.D. Evans, M. Carter, R. Panico, L. Kimble, J.T. Morlock, M.J. Spears, Characteristics and predictors of short-term outcomes in individuals self-selecting yoga or physical therapy for treatment of chronic low back pain, PM R. 2 (2010) 1006–1015. https://doi.org/10.1016/J.PMRJ.2010.07.006
60. H.E. Tilbrook, H. Cox, C.E. Hewitt, A.R. Kang’ombe, L.H. Chuang, S. Jayakody, J.D. Aplin, A. Semlyen, A. Trewhela, I. Watt, D.J. Torgerson, Yoga for chronic low back pain: A randomized trial, Ann. Intern. Med. 155 (2011) 569–578. https://doi.org/10.7326/0003-4819-155-9-201111010-00003
61. H. Cox, H. Tilbrook, J. Aplin, A. Semlyen, D. Torgerson, A. Trewhela, I. Watt, A randomised controlled trial of yoga for the treatment of chronic low back pain: Results of a pilot study, Complement. Ther. Clin. Pract. 16 (2010) 187–193. https://doi.org/10.1016/J.CTCP.2010.05.007
62. Ö. Ülger, N.V. Yaĝll, Effects of yoga on balance and gait properties in women with musculoskeletal problems: a pilot study, Complement. Ther. Clin. Pract. 17 (2011) 13–15. https://doi.org/10.1016/J.CTCP.2010.06.006
63. R.B. Saper, A.R. Boah, J. Keosaian, C. Cerrada, J. Weinberg, K.J. Sherman, Comparing once-versus twice-weekly yoga classes for chronic low back pain in predominantly low income minorities: A randomized dosing trial, Evidence-Based Complement. Altern. Med. 2013 (2013). https://doi.org/10.1155/2013/658030
64. K.J. Sherman, D.C. Cherkin, R.D. Wellman, A.J. Cook, R.J. Hawkes, K. Delaney, R.A. Deyo, A Randomized Trial Comparing Yoga, Stretching, and a Self-care Book for Chronic Low Back Pain, Arch. Intern. Med. 171 (2011) 2019–2026. https://doi.org/10.1001/ARCHINTERNMED.2011.524
65. N. GS, I. D, K. R, D. S, S. None, J. K, Changes in pain intensity and health related quality of life with Iyengar yoga in nonspecific chronic low back pain: A randomized controlled study, Int. J. Yoga. 7 (2014) 48. https://doi.org/10.4103/0973-6131.123481
66. E.J. Groessl, K.R. Weingart, K. Aschbacher, L. Pada, S. Baxi, Yoga for Veterans with Chronic Low-Back Pain, Https://Home.Liebertpub.Com/Acm. 14 (2008) 1123–1129. https://doi.org/10.1089/ACM.2008.0020.
67. E.J. Groessl, K.R. Weingart, N. Johnson, S. Baxi, The benefits of yoga for women veterans with chronic low back pain, J. Altern. Complement. Med. 18 (2012) 832–838. https://doi.org/10.1089/ACM.2010.0657
68. S.J. Kamper, T.R. Stanton, C.M. Williams, C.G. Maher, J.M. Hush, How is recovery from low back pain measured? A systematic review of the literature, Eur. Spine J. 20 (2011) 9–18. https://doi.org/10.1007/S00586-010-1477-8
69. K.J. Sherman, D.C. Cherkin, J. Erro, D.L. Miglioretti, R.A. Deyo, Comparing yoga, exercise, and a self-care book for chronic low back pain: A randomized, controlled trial, Ann. Intern. Med. 143 (2005) 849–856. https://pubmed.ncbi.nlm.nih.gov/16365466/
70. P.G. Pence, P.G. Pence, Bringing Yoga to the Veterans, (2013) 49–58. https://warriorsatease.org/wp-content/uploads/2011/06/BringingYogatotheVA.pdf