Yoga and You: A Pain Doctor’s Perspective in Treating Low Back Pain – Stability Hierarchy

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A recent guideline issued by the American College of Physicians discussing low back pain, and the use of opioids and their lack of effectiveness in treatment, has brought a focus on yoga as the first listed treatment alternative to opioids, and often the only one mentioned in media coverage of the guideline.

Now many back-pain patients, intimidated by the image of themselves squeezed into yoga pants in a class with seasoned yoga practitioners, are deciding to just stretch more at home, perhaps in the belief doing so will alleviate their pain.

As a back-pain specialist, I’ve come to recognize the relationship between flexibility and back pain is a complicated one.

Yoga is a group of physical, mental, and spiritual disciplines, today with a wide variety of Yoga practices and goals, including versions in which stretching is the primary focus.  Yoga as a physical discipline is our focus here.

Choosing the correct yoga class for your specific needs is paramount.  To accomplish this, you must first understand where you rank within the Stability  Hierarchy – your body’s bracing capability – which I break into four levels:

  • Flexible and Stable
  • Inflexible but Stable
  • Inflexible and Unstable, and
  • Flexible and Unstable

Patients in the best position are those who are both flexible and stable.  They’re the ones who have either worked very hard to maintain both attributes, or are young and have never been seriously injured.  To climb into this category is a worthy and attainable goal for most of us if approached correctly; those already there can start with any yoga class they choose.

The next level are patients who are inflexible but stable.  This includes the young adults who are involved in sport but have never been flexible; the middle-aged “weekend warriors” who’ve stayed active on a part-time basis; or the athletes with past injuries they never completely overcame.  This group needs to add flexibility to the stability they have achieved or maintained, and for them, a stretching-based yoga like hatha yoga would be very helpful.

A third group, the largest by far, has become sedentary or injured and now is both inflexible and unstable.  Many of my patients are unaware they are in this group; they think they’re in the inflexible but stable group and will attempt to gain flexibility on their own.  While flexibility is important, it should only be achieved in coordination with the effort to gain stability.  Patients with chronic low back pain caused by weak bracing muscles of the lumbar spine [the definition of unstable] often have tightness in the hamstring muscles, which tighten in an essential act of compensation to stabilize the lumbar spine.  Attempts to stretch these hamstrings in isolation are counter-productive and could lead in the long term to disc degeneration and arthritis [see No. 5 in my “Bracing Series” for a more in-depth explanation].  Patients in this group must often start with physical therapy to strengthen their bracing muscles in isolation with the hope of transitioning into a yoga class that focuses on positions and poses.

The last group – flexible and unstable – is unfortunate though small, consisting mostly of those who have always been very flexible and have become weak in their bracing muscles.  Yoga is not helpful for this group, which already focuses way too much on what they’re good at–flexibility.  These patients often need intense physical therapy followed by a transition to Pilates instead.

To recap our four categories:

Flexible & stable Those who work at maintaining both body attributes, and the uninjured young Any yoga physical discipline
Inflexible but stable Young adults involved in sports who have never been flexible, middle-aged “weekend warriors”, and athletes unrecovered from past injury Stretching-based, such as hatha yoga
Inflexible & unstable Sedentary and/or injured Physical therapy before transitioning to yoga
Flexible & unstable Flexible with weak bracing muscles Yoga not helpful

For my patients, I integrate into our TuneMe system the physical aspects of yoga which enhance stability and flexibility, even though I understand the practice of yoga at its higher levels involves elements of eastern spirituality, which as a Christian I personally reject.  I encourage my patients to continually evaluate their position within the Stability Hierarchy, and to use yoga for improving their body stability, as suggested above.