Yoga for Pain
- Foreword by Anil Kumble
- 1. Introduction
- 2. Back Knack
- 3. Smooth Starters
- 4. Flexibility
- 5. Stability
- 6. Strength
- 7. Relaxation
The past pace of life, the pressures at office or business, the management of family and coping with changed living conditions have a great impact on the quality of life. Lack of proper exercise, poor postures, long working hours, poor eating habits, the troublesome travels add up only to worsen the quality of life. The result is stress. One of the main organs that get a heavy beating in the process is the back.
Taking recourse to pain-killers as a relief measure is not only fooling the system but also spoiling the system.
Despite of great scientific progress during the past 100 years, hightech medicine and our ability to cure many diseases, including some serious spinal diseases, we still confront simple back pain with confusion, unable to offer cure. Back pain in a broad context includes the low back, upper back and the neck.
Simple, non-specific or mechanical back pain are terms used to describe a mechanical derived back pain not involving nerve root compression or serious spinal disease. This kind of back pain has become a big problem to patients, therapists and to society itself. A majority of the people, in particular the urban lot, suffers from back pain at some stage in life. and Recurrence rates of the back pain a year after an acute episode of back pain are very high.
Finding the source of pain is not enough since it is quite different from the cause of pain. Beside the possibility of referred and radiated pain, each spinal segment contains different tissues such as discs, ligaments, joints and muscles, all in a very small area. Thus, even if we identify the painful segment it does not give us any information on the specific tissue/structure responsible for the disorder, causing the pain. Hence, it is very essential to adapt an exercise program that comprehensively addresses all the intricate subsystems of the spinal column. One such safe program is YOGA.
What is yoga?
Yoga is the art and science of living. In the present day, the awareness about yoga is enormous and a lot of commentaries and other works on yoga are available. However, the works of Sage Patanjali dating back to 250 BC is a very fundamental and comprehensive treatise on yoga. Sage Patanjali’s dissertation on yoga is a collection of 196 terse, which are clear, concise, accurate and unambiguous. He has codified the essence of yoga as yogah chitta vritti nirodah
The fact that Patanjali has encapsulated the quintessence of yoga in just three words reveals the depth of his understanding – the deeper the understanding, the more concise the language. chitta means mind; vritti means fluctuations in the mind; nirodah means immune. When the mind becomes immune to the fluctuations, then an unalloyed bliss sets in and that is the state of yoga. The word immune is very special and is different from control. Whereas control implies adjustments to the system in order to maintain balance in the face of disturbances, immune essentially refers to the state of equilibrium, which is impervious to the outside and / or inner disturbances.
Yoga does not mean the suppression of thoughts that pass through the mind; the condition where the mind is free of thoughts is yoga. Although there are varied and innumerable kinds of fluctuations of mind, Sage Patanjali has scientifically classified those under five heads. Further they may be painful or pleasurable.They are pramana, viparyaya, vikalpa, nidra and smrithi.
Pramana is knowing things as they are; viparyaya is understanding in contradiction to reality; vikalpa is imagination devoid of substance, nidra is sleep and smrithi is memory. The state of mind free from all these fluctuations characterizes yoga. The individual whose mind has reached this state can be said to have reached his true state. This is what enlightenment is. To reach this state, Patanjali advocates the path of practice and renunciation. The attributes of practice are long term, regularity and enthusiasm; and that of renunciation is not to deviate from practice. Practice and renunciation are like the two wheels of a cart - both equally important for reaching the goal.
The path of practice proposed by Patanajli is a highly structured and scientific methodology called astanga yoga i.e., eight fold path.
The eight rungs are
- 1. Social discipline (yama) consisting of non violence, truth, non stealing, non coveting other’s possessions as well as a moderate life style.
- 2. Personal discipline (niyama) encompassing physical and psychological cleanliness, contentment, pursuing the set goals, self awareness and giving up ego.
- 3. Posture (asana) i.e., maintaining a physically and psychologically stable state of body.
- 4. Art and science of breathing (pranayama).
- 5. Withdrawal of senses (pratyahara) so that mind can be ready to get focused.
- 6. Concentration (dharana) which provides one pointedness to the mind.
- 7. Meditation (dyana) providing a state of absorption with an object / thought.
- 8. Contemplation (samadhi) in which the distinction between the seer and the seen disappears.
These eight rungs of yoga need not be seen as independent steps; instead they are inter-dependent. The practice of all these rungs of yoga is very essential. Of these, in this book, we describe a few important postures, breathing and relaxation techniques that are relevant in the context of a healthy back.
Sthira means stable; sukham means comfortable. The main attributes of a posture are stability and comfort. Stability should be seen as an aid to comfort and comfort should always ensure the stability. This forms the basic premise for any asana. For this, an asana has to be performed with awareness. Awareness comprises of musculoskeletal, neurological and psychological dimensions. For this, good breathing (pranayama) is imperative. With practice, stability can be achieved without effort. If and when this happens, the asana becomes effortless and the mind gets absorbed. In the words of Patanjali
When asana practice reaches this level - the musculoskeletal system will be in balance i.e. all the muscles will be without conflict; the neuromuscular functioning will be harmonious; and the mind will be calm i.e. undisturbed. This is the effect of asana. Sage Patanjali has summarized this effect as
Then, the dualities cease to exist and the mind becomes one-pointed.The postures do not just provide stretch to the muscles; they go far beyond – soothing, detoxifying and vitalizing. It paves way for a new and better understanding of us – instilling confidence and vigor. A machine if not well-aligned cannot run smoothly – it creates a lot of noise. The rubbing of parts not only impairs the quality of the product produced but also wears out quickly. Similarly, if our bones, muscles, tendons, and ligaments are not properly oriented, problems could set in early and our quality of work and life may be impaired. So, a well-aligned body is imperative for a healthy and effective functioning. Good stretching improves blood circulation and lymphatic drainage. Proper stretching in collate with goodbreathing enhances the functioning of the heart and the lungs
Caution and Precaution
Before you get started on a yoga program for back pain, take the advice of your doctor. Your doctor will evaluate your fitness level in relation to your back pain and may suggest about the do’s and don’ts, especially if the severity of the pain is very high.It is always better to know why we are doing what we are doing. For this, an elementary knowledge about the spinal column, the main organ at stake in back pain, is desirable.
Brief Anatomy of Spinal Column
The back bone is as much a living system as we ourselves are – it is not a simple mechanical structure. It responds to our emotions, stress and bliss. A basic understanding of the back and its functions helps not only in experiencing the depth of the posture but also in appreciating the wonders we possess.
The spine has three different functions that are to be met –
- 1. support of body and the loads we carry
- 2. movement
- 3. protection of the spinal cord
Meeting these functions causes problems since the spine has to be stable yet mobile at the same time. Hence, a balance between the different structures comprising the spine is important. The plasticity of the column lies in its make-up, i.e., multiple components superimposed on one another and interlinked by ligaments and muscles.
The concept of spine stability
The spine is meant to carry loads, allow movement of the different body parts, and provide protection to the spinal cord. Therefore it needs both rigidity and flexibility which are achieved by its unique structure The spinal stabilizing system consists of three subsystems.
- 1. the passive subsystem – vertebrae, intervertebral discs, spinal ligaments, joint capsules, and the passive propertiesof the muscles
- 2. the active subsystem – active properties of muscles and tendons
- 3. the neural subsystem – proprioceptors and other neural control components
The three subsystems complement each other and work together to achieve stability. These subsystems have a highly coordinated feedback network system in order to stabilize the spine. For any reason, if this network becomes ineffective, back pain ensues. Dysfunction of one or more of the stabilizing components results in an attempt to compensate by one of the other components in order to keep the spine stabilized. The three subsystems are adaptive to either chronic dysfunction of other components or to increased functional demand on them. Dysfunction of the passive subsystem may be due to mechanical injury or degenerative disease. Compensation will follow in the active subsystem. Dysfunction of the active subsystem may be due to disuse, injury or disease and may compromise the system’s ability to respond when needed. A dysfunction of the neural subsystem may result from damage to transducers, conducting nerves or Central Nervous System. This leads to defective function of the active subsystem and may become chronic.
Basic structure of the spinal column Back consists of several components - Vertebrae, nerves, discs, ligaments, muscles and tendons
- Discs function as the shock absorbers of the spine
- Discs consist of jelly-like center surrounded by fibrous rings of connective tissue
- Nerves travel down from the brain and group together to
form the spinal cord
- Carry messages to and from various parts of the body
- Allow for movement and other functions
- Tendons are bands of tough, fibrous tissue that connect muscle to bones
- Ligament are tough connective tissue that connect bones to bones
- Muscles provide support and movement for the spine
Spine is made up of 24 small bones (vertebrae) that are stacked on top of each other to create the spinal column. Each vertebra consists of two main parts: the massive body in the front (anterior) and the vertebral arch in behind (posterior). The arch itself is a collate of various parts: the pedicles, lamina and a spinous process. The thickened junctions between the pedicles and laminate have superior and inferior articular facets and a laterally projecting transverse process. The opening between the body and arch is called vertebral canal through which the spinal cord passes.
The superior processes of a vertebra extend upwards and join with the inferior processes of the vertebra directly above it; similarly, the inferior processes of the vertebra extend downwards and join with the superior processes of the vertebra directly below it. These joints are called the facet joints. The facet joints link the vertebrae together and give them the flexibility to move against each other.
Between each vertebra is a soft, gel-like cushion called a disc. The disc has an outer slightly harder ring called annulus fibrosus and an inner softer region called nucleus pulposus. The disc, besides allowing movement between vertebrae, acts as a shock absorber and weight bearer. It also keeps the bones from rubbing against each other. Each vertebra is held to the others by groups of ligaments. Ligaments connect bones to bones; tendons connect muscles to bones. There are also tendons that fasten muscles to the vertebrae. The spaces between the pedicles of adjacent vertebrae form a series of openings called intervertebral foramina. The branches of the spinal nerves exit through these foramina
The cervical spine begins at the base of the skull. Seven vertebrae make up the cervical spine with eight pairs of cervical nerves. The individual cervical vertebrae are abbreviated C1, C2, C3, C4, C5, C6 and C7. The cervical nerves are also abbreviated; C1 through C8.
The Thoracic spine is located in the chest area and contains 12 vertebrae. The ribs connect to the thoracic spine and protect many vital organs. The thoracic levels are T1, T2, and T3 through T12. Similarly the lumbar levels are L1 through L5 (or L6).
The Lumbar Spine
The third part of the spine is the lumbar vertebrae. There are normally five lumbar bones. These vertebrae are the largest and strongest of the three regions (cervical, thoracic, and lumbar) because these carry the bulk of the body's weight. Five pairs of lumbar nerves manipulate the movement and sensory functions of the lower extremities. L5 vertebra is the biggest of all five and transfers the weight to the sacrum.
The Sacrum and Coccyx:
The sacrum is simply S1. The coccyx is not abbreviated or numbered. With the exception of the atlas, axis, sacrum and coccyx, each cervical, thoracic, and lumbar vertebra is similarly shaped.
The curvatures of the vertebral column
The vertebral column as a whole is straight when viewed from the front or the back. In some people, however, there may be a slight lateral curvature which remains within physiological limits.
On the other hand, in the sagittal plane the vertebral column shows the following four curvatures:
- 1. the sacral curvature, which is fixed as a result of the total fusion of the sacral vertebrae. It is concave posteriorly;
- 2. the lumbar curvature, concave posteriorly;
- 3. the thoracic curvature, convex posteriorly;
- 4. the cervical curvature, concave posteriorly; When one is standing normally, the posterior part of the head, the back and buttocks lie tangential to a vertical plane, e.g., a wall.
The lumbar facet joints are well innervated and contain mechanoreceptors activated when the joints capsule is stretched or when the joint is under compression, mainly in extreme extension.
Sacrum and Pelvis
The pelvis is a funnel-shaped group of relatively flat bones, higher in the back than in the front. Because the joints between the bones of the pelvis allow very little motion, the pelvis effectively functions as a single bone. The sacrum (made up of 5 unified vertebrae) portion of the spinal column sits on the pelvis to form a stable joint– the sacroiliac joint. The end of the spinal column (the tailbone and the flat, triangular bone called the sacrum, which is formed by the fusion of the last five vertebrae) forms part of the back wall of the pelvis, and the upper ends of the thigh bones insert into sockets in its side walls. Thus, the pelvis joins the spine to the legs.
The shape of the sacrum gives it strength and enables the transfer of forces between the spine and the lower limbs while maintaining stability. This shape together with elements of the joints surface and ligaments provide stability to the sacroiliac joint.
Because the end of the spine (the sacrum) forms part of the pelvic funnel, the position of the pelvis has profound effects on the lumbar curve. You can experience this connection by performing this simple exercise: Sit on a firm chair with a flat seat. Tilt your pelvis forward so your navel moves forward toward your knees and your tailbone moves up and back. With your hands on your back, feel how this motion increases the lumbar curve to a more swaybacked position. Now tilt your pelvis backward by tucking your tailbone and moving your navel toward your spine. Notice how your lumbar spine flattens.
Muscles That Act on the Spine
The bony structures of the spine and pelvis are supported and moved by many different muscles, whose condition can profoundly affect the state of the back. If any of these muscles are tight or weak, they can create or worsen back pain. Running parallel to your spine are the para-spinal muscles, deep muscles of the back that function as guy wires to support the spine in the upright position. (To feel the para-spinals, put your hand on your back at waist level. The slight bulges you feel on either side of the spine are formed by the para-spinal muscles.)
The para-spinals rotate the spine, bend it backward and sideways, and influence posture by helping create and maintain the proper spinal curves. If the para-spinals are too tight, they contribute to a swayback. If they are too stretched out, they contribute to a flat back. If they are overworked, they can go into painful spasms. Yoga helps maintain back health by both stretching and strengthening the para-spinals.
The lower back is also significantly influenced by three sets of muscles that attach to the pelvis or the lumbar vertebrae: the hip flexors (which raise the thigh toward the chest), the abdominals, and the hamstrings (the long muscles on the back of the thigh). By altering the forward or backward tilt of the pelvis, these muscles can increase or decrease the lumbar curve. For example, because the hip flexors attach to the front of the pelvis, tight hip flexors tilt the pelvis forward, creating a swayback. Tight hamstrings tilt the pelvis backward, creating a flat back. Weak abdominal muscles allow the pelvis to drop forward and fail to support the lumbar spine from the front. All these conditions cause undue stress on the lower back muscles and in the long run cause pain and discomfort.
The abdominal muscles have a great bearing on the health of the back. The abdominal muscles include three flat and broad muscles and two vertical ones. They, also, are organized in layers
- 1. External Oblique – The largest and most superficial of the flat muscles, originates from the outer surface of the ribs
- 2. Internal Oblique – Lies beneath the external oblique
- 3. Transversus Abdominis – The deepest of the three flat muscles
- 4. Rectus Abdominis –A vertical muscle
The hip muscles (gluteus minimus, medius and maximus) also play a vital role in the health of the back. The health of the spinal column depends on three important attributes: strength, flexibility and stability. Of these, stability is very crucial – many a times, injuries result from lack of stability rather than lack of strength or flexibility. Strength concerns the muscles and ligaments; flexibility is related to joints, muscles, tendons and ligaments; stability has deeper implication – the inner unit.
The Inner Unit indicates the functional synergy between the transversus abdominis and posterior fibers of the obloquies internus abdominis, pelvic floor muscles, multifidus and lumbar portions of the longisssimus and iliocostalis, as well as the diaphragm. In addition, the thoracolumbar Fascia has a significant role to play. This fascia covers the back. The thoracolumbar fascia is well innervated and contains mechanoreceptors.
This might indicate the importance of the fascia in control and stability of the lumbar spine. Research shows that the inner unit is under separate neurological control from the other muscles of the core. This explains why exercises targeting muscles such as the rectus abdominis, obliquus externus abdominis and psoas, is very ineffective at stabilizing the spine and reducing chronic back pain.
Exercising the big muscles (prime movers) do not provide the correct strengthening for such essential small muscles as the multifidus, transversus abdominis and pelvic floor muscles. When working properly, these muscles provide the necessary increases in joint stiffness and stability to the spine, pelvis and rib cage to provide a stable platform for the big muscles.
Consider the case of picking a weight from the floor. Almost in synchrony with the thought, "Pick up the weights from the floor," the brain activates the inner unit. contracting the multifidus and drawing in the transversus abdominis. This tightens the thoracolumbar fascia in a weight belt-like fashion. Just as this is happening, there is simultaneous activation of the diaphragm above and the pelvic floor below. The effect is to encapsulate the internal organs as they are compressed by the transversus abdominis. This process creates both stiffness of the trunk and stabilizes the joints of the pelvis, spine and rib cage, allowing effective force transfer from the leg musculature, trunk and large prime movers of the back and arms to the weight on the floor. Muscles should be recruited in the correct sequence, intensity and time for maintaining the health of the back. In some persons, the inner unit is not activated, and they are likely to face of the risks of bad-back episodes. It is also found that in persons suffering from low-back pain, the inner unit is dysfunctional. Therefore, it is necessary that the inner unit, which is the foundation for a healthy back, is trained properly. Yoga is a great tool in this direction.