back pain – Essential Physical Therapy

Almost everyone will struggle with back pain at some point in their lives. For some it comes and goes, for others it’s a once in a while thing, and for others it becomes a part of their lives.

What’s even more concerning is that the outcomes for surgery for back pain are not that great. Several studies have shown that long term results for patients who had surgery for their back pain were the same as those who were treated with exercise and cognitive therapy.

Why doesn’t surgery work?

Our spines are complex, we humans are complex! The thinking that the source of the pain is always at the location of the pain is almost always wrong unless you had a direct trauma to that area.

This is because we compensate, and we do it really darn well.

Have you ever had to wear a cast or boot after spraining (or breaking) your ankle or your foot? Maybe you even had to use crutches. Soon, your arms, neck, and hips and probably some other body parts will start to hurt. (Don’t worry, I’ll get back to the back pain soon, stick with me here!)

But there was no direct injury to anything except your ankle! The pain in those other areas occur because you are compensating for not being able to use your foot properly.

The problem is, we all have histories of injuries that make us compensate slightly, and underlying all of that we have an asymmetrical brain and an asymmetrical body that will make us prefer to do things differently on one side than the other.

That’s not really a problem if you’re a wild human foraging for berries or climbing trees all day. But if you’re a modern human, you’re forced into positions (sitting at your desk or your car) and actions (writing, typing, opening doors) that your body will do over and over and over again on the same side.

This creates asymmetries that become ingrained, and now we have to compensate somehow.

So what does this have to do with back pain?

The Postural Restoration Institute, or PRI, clarifies how these asymmetries affect us and can cause problems. Here is a brief synopsis of why and how our asymmetrical nature impacts our lives…

We have a more stable, domed, strong diaphragm on the right accompanied by a flatter, weaker diaphragm on the left. this makes us feel much more comfortable standing over our right leg.

This orients our pelvis slightly to the right.

But nobody walks around with their body pointed to the right! No, we compensate to bring our chest back around to the left, so we can see where we’re going.

So, basically, our pelvis is pointing right, while our ribcage is pointing left. With walking and other alternating activities, we alternate by turning our pelvis to the left and ribcage to the right, but because of the strong anatomical tendencies listed above, we can lose this ability to alternate symmetrically.

Over time, or with repetitive activity, or injuries, we can become “stuck” in this twist. Some degenerative changes can occur, but the research unequivocally shows that disc degeneration or arthritis is usually NOT the cause of back pain (in studies where they scanned hundreds of people, some with back pain and some without, there was no correlation with back pain and arthritis/disc disease or other imaging findings. In fact, some people had severe pain and no findings on imaging, while others had severe degeneration, arthritis, and bulging discs, but no pain)!

The key to getting out of back pain for good is not going under the knife, but rather learning how to bring your pelvis back around to the left, and your trunk back around to the right.

To do so, breathing must become re-organized and re-balanced (remember that the diaphragm is the start of all this asymmetry!) and new movement patterns need to be established.

One very simple thing you can do to start training your body out of compensation is working on getting your left lower ribs down, in, and back. This will promote doming of the left diaphragm and bring your trunk back to a neutral position over your pelvis.

Here’s how to start re-orienting your ribcage to untwist your spine:

References:

Weber H. Lumbar disc herniation. A controlled, prospective study with ten years of observation. Spine (Phila Pa 1976). 1983;8(2):131.

Chou R, Baisden J, Carragee EJ, Resnick DK, Shaffer WO, Loeser JD. Surgery for low back pain: a review of the evidence for an American Pain Society Clinical Practice Guideline. Spine (Phila Pa 1976). 2009;34(10):1094-1109. doi:10.1097/BRS.0b013e3181a105fc

Brox JI, Nygaard ØP, Holm I, Keller A, Ingebrigtsen T, Reikerås O. Four-year follow-up of surgical versus non-surgical therapy for chronic low back pain. Ann Rheum Dis. 2010;69(9):1643-1648. doi:10.1136/ard.2009.108902

Rao D, Scuderi G, Scuderi C, Grewal R, Sandhu SJ. The Use of Imaging in Management of Patients with Low Back Pain. J Clin Imaging Sci. 2018;8:30. Published 2018 Aug 24. doi:10.4103/jcis.JCIS_16_18

Wáng YXJ, Wu AM, Ruiz Santiago F, Nogueira-Barbosa MH. Informed appropriate imaging for low back pain management: A narrative review. J Orthop Translat. 2018;15:21-34. Published 2018 Aug 27. doi:10.1016/j.jot.2018.07.009

Lateef H, Patel D. What is the role of imaging in acute low back pain?. Curr Rev Musculoskelet Med. 2009;2(2):69-73. doi:10.1007/s12178-008-9037-0

You got into yoga to relax and get some exercise. But, as you lie in corpse pose at the end of the class you find yourself wondering, “how the heck am I supposed to relax when my back is killing me?” You intended to be doing something good for your body, not hurting it!

This was me for a long time. Yoga has many wonderful health benefits, but it is also a common culprit in creating back pain. When I first started doing yoga, and actually many years into my practice, I loved the way it made me feel but couldn’t help noticing that my back pain was getting worse, not better. Many of my patients have been told by their doctors to try yoga for back pain, and end up with no change or even worse pain! In this article I’ll share with you the most common reason why yoga causes back pain and how to get rid of it. I’ve worked with many patients to get them back to yoga without back pain, and you can do it, too.

Breathe Better to Relieve Your Lower Back Pain

Modern yoga tends to have a lot more extension based postures (i.e. backward bends) compared with traditional yoga practices.

Yoga Postures that commonly cause back pain:

Upward facing dog pose
Bow pose
Camel pose
Basically any pose where your spine is arched back.

I am not sure why backward bends have taken a forefront in today’s yoga, maybe it’s because they look pretty? However, they can be very problematic to our backs for several reasons.

It’s not that backward bends are inherently bad, but rather they require a certain amount of stability and skill before they can be performed correctly. I was always very flexible, so it was easy for me to contort myself into all kinds of crazy postures. However, when you do back bends without the right stability, they create a lot of compression in you lower back which causes back pain and sometimes sciatica. Improper backward bending can also force us into bad breathing patterns.

Let’s maybe not go for this until we’re ready…

Ditch the Belly Breathing

One thing we need in order to bend backward without pain is a strong connection between our front lower ribs to our front upper pelvis. This means you need your abs to be working, and in the right way. And you need to be able to MAINTAIN that abdominal contraction as you inhale, i.e. no belly breathing!

Whaa???

You heard me right. Belly breathing is not good for you, especially not in a back bend. In fact, in a backward bend, it’s actually really bad for you! I know, everyone talks about all the amazing benefits of belly breathing, but hear me out.

Belly breathing (pushing your stomach out when you inhale) doesn’t allow you to maintain an abdominal contraction while you inhale, so your lower back has no support and basically gets way too compressed. This is painful and damaging if done repeatedly.

Secondly, belly breathing teaches you to breathe without moving your ribcage. When your ribcage becomes rigid, you are forced to move more from your lower back, creating it to be even more unstable and painful.

To breathe correctly in backward bends (and in general when doing physical activity) you should be able to move your ribcage and maintain some tone in your abdominal muscles, particularly the abdominals on the sides (obliques and transversus abdominus).

Exhale Focused Breathing for Back Bends:

pubic bone to demonstrate pelvis position to avoid lower back pain

Exhale completely and feel your lower front ribs drop down towards your pelvis and in towards your body.
Simultaneously draw your pubic slightly up towards your belly button.
Pause there, at the bottom of the exhale, for 3-5 seconds.
Then, quietly inhale without losing this ribs to pelvis connection. You should feel air move into your upper chest and maybe your upper back.

This breathing pattern teaches your core to turn on in the correct way, and stabilizes your back. Obviously, as you bend backwards, your abdominal region will lengthen, but you want to keep that action of lower ribs moving toward the front of your pelvis and the front of your pelvis curling up towards your ribs as you do so.

Some of us are already pretty arched in our lower back to begin with. If you are arching more on top of that to backward bend, you’re going to be in trouble. If you’re like me, and backward bending is really easy for you without much practice, you really need to work on developing some core stability before diving deep into backward bends.

Developing Core Strength

In forward bends and standing postures, keep trying to find that position of exhaling lower front ribs down and in, and bringing pubic bone up towards your belly button.

Use your Legs to Develop Core Strength for Back Bends:

In addition to exhale focused breathing, think about drawing your inner thighs towards one another, and rolling your inner thighs back behind you.
this is called hip adduction (together) and internal rotation (turning inward).
These actions are only helpful if you have the first concept of ribs down and pubic bone up, so if that is hard for you then work on that for a while before adding the leg actions.

These actions of hip adduction and internal rotation create spaciousness in your lower back and create stability in your stabilizing musculature, particularly in the pelvic floor muscles. the pelvic floor is a sling of muscles inside of your pelvis that assists your abdominals in stabilizing your lower back.

You can think of drawing your inner thighs together even when they are apart. Take anjaneyasana, or kneeling lunge, for example.

Instead of leaning forward into the lunge to stretch the front of your hip (and arching your back and losing all sense of internal stability) stay more upright, find ribs down and pubic bone up.
Then, draw inner thighs towards one another as if you were trying to close the gap between your legs without actually moving.
This may not look as pretty or as deep as in the picture, but it will feel a whole heck of a lot better, and will teach your body so much in regards to strength, true flexibility, and good habits.

Develop Good Habits

Before jumping into backward bending, spend some time in standing postures and forward bends, working on bringing your lower front ribs down and in, bringing your pubic bone up towards your belly button, feeling air in your upper back, and drawing inner thighs together and back. Only once you have this well established should you explore deeper backward bends.

Once you are ready to start experimenting with backward bending , a good place to start is with some gentle standing backward bends.

Start With a Gentle Back Bend:

Establish your lower front ribs down and in on an exhale, as well as pubic bone up.
Then, draw inner thighs together and roll inner thighs back.
From there, cactus your arms and see if you can gently arch your upper back WITHOUT letting your lower front ribs pop up or your pubic bone moving down away from your belly button.
You probably won’t go as far back and that’s okay, because now you’re actually lengthening your front body in a healthy way that supports your spine instead of just dumping into your lower back.

It’s always good to follow backward bending with a counter pose, which would be a forward bend. Child’s pose is great, or seated forward bend. However, try not to just flop into these poses, either. Remember the same actions from above (low ribs in, pubic bone up, inner thighs together and back) while forward bending as well.

Final Thoughts

The real practice of yoga is about being with ourselves in the moment. When we’re in a class, or even by ourselves, we may have ideas of how a pose should look or what we think we should be able to do. However, if we do not take time to establish a good foundation, or if we push our bodies beyond our limits, we will get feedback. In the case of excessive back bending, feedback will occur in the form of physical pain.

This is where the real yoga starts. Can you listen to your body and let go of what it’s “supposed to” look like, and meet yourself where you are? That is probably the biggest challenge, but will provide the greatest reward when you find that you can practice longer and more often because you are not limited by pain and injury.

Tag: back pain

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