Managing Pain (LBP) with Yoga
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’tlose 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.
- Dopractice 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’tlet 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.
- Domaintain 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’tround 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.). 
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