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Yoga for Back Pain: Enhancing Body Awareness to Facilitate Healing

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Dr. Loren Fishman is a pioneer in the use of yoga as an adjunct therapy in physical medicine and rehabilitation. His groundbreaking work with yoga therapy has been profiled by Jane Brody in The New York Times and in numerous other leading media outlets. Ellen Saltonstall is a yoga therapist and co-author with Dr. Loren Fishman of several books on the therapeutic use of yoga for healthy aging, including Yoga for Osteoporosis and Yoga for Arthritis.

In this interview, they discuss two new review studies on the effects of yoga for back pain and other chronic pain issues and explore ways in which yoga facilitates self-healing.

Dr. Fishman, Jane Brody of The New York Times, wrote an article about your work a little more than a year back, saying that "to many of Dr. Fishman's patients, he is a miracle worker, who treats their various orthopedic disorders without the drugs, surgery or endless months of physical therapy most doctors recommend." What's the secret to getting those kinds of results in your work?

Dr. Loren Fishman: Well, to paraphrase a saying: "A miraculous deed is one that occurs in a culture with a more advanced technology than the one calling it a miracle." When it comes to medicine, people are used to the very material approach that if you cut here and you take that out, then it will no longer be causing a problem.

I use yoga as therapy in my practice, because it offers an innocuous but highly-effective means of curing or relieving a large number of musculoskeletal conditions. At the most basic level, yoga allows people to connect more deeply with their body and develop a sense of the underlying cause of what's going wrong in their body.

So results are not just limited to chronic pain issues like back pain. It applies to a whole spectrum of things that cause human suffering. Once you quiet down enough to sense whatever it is that you're doing wrong, be it bad biomechanics, poor lifestyle habits, chronic stress, or whatever, you can undo those habits, and things tend to clear up.

Yoga works well in combination with medicine. I simply find out what is wrong using strictly medical means: EMGs, MRIs, and so on. Then I use the yoga and the knowledge that my teachers, Mr. B.K.S. Iyengar and others, have given to me to figure out what to do to reverse and relieve the condition. But you really need the medicine to first find out what the condition is.

The effects of yoga on back pain are among the most studied health benefits of yoga. Just in the last three months, two new review studies were published: one in the Clinical Journal of Pain, which looked at the overall effect of 10 studies on the effect of yoga for chronic back pain. Another study in Musculoskeletal Care reviewed 17 studies involving more than 1,600 people with either low back pain, osteoarthritis, rheumatoid arthritis, kyphosis, or fibromyalgia. Both the reviews found that consistently, across all the studies reviewed, yoga turned out to have a positive effect in terms of reducing pain and also on the disability that often accompanies these chronic pain conditions. How can yoga have an effect on so many different conditions?

Dr. Loren Fishman: Back pain and other musculoskeletal conditions often result from unconscious habits, i.e., things we do day in and day out. We may sit in a chair at work every day that makes us slump. Or, we may be carrying things with bad biomechanics, which is often the cause of musculoskeletal difficulties and even herniated discs. So, once you learn to undo those and unwind the soft tissues, you can see great results.

And with yoga, you don't just shape the body. Yoga is also really a behavior modification program: You shape the mind. You shape the approach to the problem. You shape behavior. And people do the practice, quite willingly and quite cooperatively, because -- nicest of all -- it works.

Ellen Saltonstall: When yoga is taught in the right way, it really encourages developing greater mind-body intelligence. The way I teach yoga, and the way many teachers do, we try to not make it a mechanical repetition of postures. Rather, we try to encourage students to really understand what they're doing in each posture, and to work in a methodical, careful way.

So yoga is not about just taking your position or watching television while you ride a bike for 15 minutes. It's really about concentrating and being present in your body. It's about quieting down and focusing on what you're doing. It's about learning to move energy in a beneficial way through your body. And that is something you have to learn if you've developed a chronic pain condition due to poor habits.

Particularly with musculoskeletal causes of back pain, the underlying driver is often musculoskeletal patterns that are detrimental -- which often result from our unconscious habits of how we move and use our bodies. So, there's apparent education that happens in yoga that develops greater awareness, a deeper awareness not only [of] your physical activities, but the patterns of your mind.

Ellen, you also work with yoga as therapy for people who may have tried physical therapy but have not gotten the results they were looking for. What do you feel you have to offer that helps make a difference?

Ellen Saltonstall: With most people, there's a lot of work to do to just educate them about their body and proper biomechanics. So first of all, we look at whether there are postural habits or habitual movements that might be contributing to their difficulty. After that, we try different yoga poses and we find which ones work well.

There's an art to really finding the right modification to work for different people, the right props, the right description, the right kind of verbal cues that will help elicit a different action from them and help them make introduce new habits and erase the old musculoskeletal patterns that don't serve them. Sometimes you find the right cue and it is like a miracle. It's wonderful.

You said there's a lot of work to be done just educating people about their body. Can you give an example of how people can improve simply by learning more about their body and how it works?

Dr. Loren Fishman: Well, there are so many. But for example, I had a recent case with a woman, a college professor in her early 60s. She suffers from a condition in which her body is making too many red blood cells. Because of this condition, she gets bad cramps in her back, in her legs, and elsewhere.

You know what they do to save this woman from these cramps? They bleed her. It sounds like 14th century medicine, but it's effective. It works because blood cells come out and fluid is drawn into her vascular system. It works for a few weeks, then it needs to be done again, because her body keeps making too many blood cells.

So in our office, we taught her ways to stretch her muscles in simple ways. Stretching is like wringing a wet cloth, the fluid is drawn out, and when you stretch in different dimensions, the fluid is drawn out in many ways.

Stretching the muscles and the capillaries also gives the vascular system a greater volume. When it stretches out, it's like making a road longer. Finally, by squeezing the muscles like that, you relax them. So just simple poses like Paschimottanasana (seated forward bend) gave this woman extreme relief. Perhaps best of all, she got greater control of her condition and doesn't have to go to the doctor every two weeks to get bled.

Obviously, someone suffering from chronic back pain would not want to go into your run-of-the-mill yoga class. So what would you recommend to someone with back pain who is interested in trying yoga?

Ellen Saltonstall: If you have back pain issues, it's really important to evaluate the class and the teacher. Avoid fast-paced classes with little instruction in how to do things correctly. That's not what you want if you have back pain.

So one option is to look for a trained yoga therapist. There are many yoga therapy training programs now that train yoga teachers to work with people with specific problems. If that is not possible, or if you prefer to go to a yoga class, look for a teacher, who is going to pay attention to how you're doing the poses and who can teach you modifications, if you need it. Avoid classes with a large number of students. If there are more than 10 to 15 students in the class, the teacher won't have time to show you the modifications you need. But for someone with chronic musculoskeletal conditions, a couple of individual sessions is often the best place to start.

Once they get started, however, yoga really empowers people. They may come in thinking, "Oh, I can't do yoga. I'm too stiff." But there are so many different things that you can do that don't require a lot of flexibility. And you can modify the poses that do require flexibility. Empowerment is so important.

Dr. Loren Fishman: When people have the ability to do something for themselves, they don't become depressed from their own powerlessness, their own victimhood. So one of the key things about yoga is that it gives you the ability to do it yourself. For many conditions, such as fibromyalgia and chronic back pain, if you get a little control over the condition, it can change things tremendously.

This is an abbreviated version of a 30-minute interview, in which Dr. Fishman and Ellen Saltonstall discuss keys to keeping the back healthy. Download the full recorded interview here: "Yoga for Lifelong Back Health."

Join Dr. Loren Fishman and Ellen Saltonstall online! Learn about the seven causes of back pain, and which yoga postures are suitable for different types of conditions (and which to stay clear of). This is a two-part online course, suitable for yoga teachers and experienced yoga practitioners. See details here: "Yoga for Back Pain: Keys to Safely Preventing and Relieving Back Pain."

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