Low Back Pain: A Better Remedy?

Core Strength

The term “core strength” seems to be one of the most commonly used phrases when discussing health and fitness. Most group fitness classes include a core section or are solely focused on core strength. Magazine headlines highlight new core exercises to improve strength and stability. Experts tout the importance of strengthening the core to improve balance. Yoga instructors direct participants to engage the core. Core strength seems to be the newest fitness trend, but is it more than a fad?

A strong core doesn’t necessarily equate to well-defined six-pack abs like you see in a swimsuit magazine. The muscle group responsible for the six-pack, the rectus abdominis, is only one of the many groups of muscles that make up the core. The core consists of the groups of muscles in the trunk and back. These muscles are located deep within the abdomen and back, and attach to the spine or pelvis. They wrap around the internal organs and help to stabilize the torso and spine. The core is made up of the pelvic floor muscles, transverse abdominis, rectus abdominis, multifidus, obliques, erector spinae, and diaphragm. Minor core muscles include the latissimus dorsi, gluteus maximus, and trapezius. The core muscles help with running, jumping, twisting, bending, bracing, and breathing. They are responsible for posture, stability, and balance.

The core muscles work together to create a foundation of strength and stability and help the body avoid imbalance. The term “imbalance” here is different from losing balance. Core imbalance refers to the difference between muscles that are too weak or too strong, or too tight or too loose. A combination of some core muscles being too weak while others are too strong can lead to poor posture or anatomical misalignment, which could lead to pain and injury. A strong core stabilizes the spine and improves posture. The core muscles take the strain off of the muscles in the arms and legs in everyday movements, which can prevent injury and pain in the back, hips, knees, and neck.

Yoga and Low Back Pain

One less often utilized treatment for low back pain is yoga. Yoga activates and strengthens the core in many ways. Through the practice of yoga, one learns to control their breathing and participate in different breathing techniques that contract the abdominal wall and pelvic floor muscles. Yoga poses require engagement of the muscles in the core as the body moves through and holds poses, and practices balance. This builds abdominal strength and stability by using several muscle groups in the core at the same time, leading to increased strength in all of the muscles of the core. The practice of yoga helps to stretch and strengthen the muscles that support and align the spine, leading to improvement in flexibility, posture, and relief of pain.

A systematic review and meta-analysis studying the use of yoga for the treatment of low back pain assessed the efficacy and safety of using yoga as a treatment for patients with low back pain. The study reviewed previous randomized controlled trials that compared the use of yoga with other forms of conservative treatment usually used for the treatment of low back pain.

The researchers focused on the outcomes of the study, specifically improvements in pain intensity and pain-related disability. The results were reviewed over both short-term and long-term follow-up. 30 articles were reviewed on 27 individual studies, leading to a pool of 2,702 participants. When compared to passive control, yoga was associated with:

• Moderate improvement in pain intensity
• Moderate improvement in pain-related disability
• Mild improvement in mental health
• Mild to moderate improvement in physical functioning

The study revealed that the effects were sustained long-term, with the exception of mental health. However, due to study design, these results were not found to be clinically significant.

The results found in this study are similar to a systematic review and meta-analysis studying the use of yoga as a treatment for low back pain published in 2013. The study method was the same, reviewing 10 randomized controlled trials, giving a pool of 967 participants. The researchers found similar results. There was evidence of:

• Significant improvement in pain
• Significant improvement in back-specific disability
• Global improvement

There was strong evidence of long-term effects on pain, and moderate evidence of a long-term effect on back-specific disability.

Should Yoga Be Considered In My Claims?

Practicing yoga with a certified instructor is a safe and effective way to improve mobility and posture, increase strength, and relieve pain. Yoga can be used not only as a treatment, but as a way to prevent low back, knee, hip, and neck injuries.  The benefits of yoga practice go beyond core strengthening and pain relief. The practice of yoga incorporates mindfulness, which is associated with decreasing stress and anxiety, and reducing the perception of pain.

Consider yoga for the treatment of patients with acute or chronic low back pain in an effort to relieve pain, increase strength and flexibility, and reduce reliance on medication. If a treating physician requests authorization, strongly consider approving the request, or be sure your utilization review partner understands the benefits of using yoga for the treatment and prevention of low back pain.  We've learned a lot over the past decade about how not to treat back pain (e.g. long term opioids) and the importance of the biopsychosocial model for pain patients.  The data is clear, and evidence suggests that yoga is a safe alternative for the treatment of low back pain that is likely to reduce pain and increase function. 

By Aliza Krug, PA-C

Aliza Krug is a Certified Physician Assistant and is the Clinical Director of Arbicare, a Utilization Management Organization focusing on improving the care of injured people. She has more than a decade of experience working with patients in both an urgent care and orthopedics setting, and has helped numerous injured workers in a clinical setting.

• Anheyer, D., Haller, H., Lauche, R., Dobos, G., & Cramer, H. (2021). Yoga for treating low back pain. Pain, Publish Ahead of Print. https://doi.org/10.1097/j.pain.0000000000002416
• Cramer, H., Lauche, R., Haller, H., & Dobos, G. (2013). A Systematic Review and Meta-analysis of Yoga for Low Back Pain. The Clinical Journal of Pain, 29(5), 450–460. https://doi.org/10.1097/ajp.0b013e31825e1492

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