Yoga for Back Pain:

Keys to Safely Preventing and Relieving Back Pain

A Yoga U Online Course

with

Dr. Loren Fishman and Ellen Saltonstall

Transcript, Session 1

Eva Norlyk Smith: Hello, everyone. This is Eva Norlyk Smith with Yoga U Online.

Welcome to session one of our two-part course with Dr. Loren Fishman and Ellen

Saltonstall on Yoga for Back Pain: Secrets to Safely Preventing and Relieving Back

Pain. I am very pleased to welcome back popular Yoga U presenters, Dr. Loren

Fishman and Ellen Saltonstall. Dr. Loren Fishman and Ellen Saltonstall are

co-authors of several books on the therapeutic use of yoga including Yoga for

Osteoporosis and Yoga for Arthritis. Dr. Loren Fishman specializes in physical

medicine and rehabilitation, and he has been using yoga as an adjunct therapy in

his medical practice for more than 30 years. In fact, Dr. Fishman is such a pioneer

in the use of alternative approaches to back pain and other chronic pain issues that

his work using yoga as therapy in his medical practice was profiled by health writer,

Jane Brody in the New York Times a little while back.

Ellen Saltonstall is an author and works as a yoga therapist in her studio in New

York City. Ellen has a vast background in movement therapy. She holds a masters

degree in the field of therapeutic movement education, and shes a senior teacher

of the kinetic awareness program for myofascial release. She is particularly

renowned for her work using yoga programs for repetitive sprain injury,

menopause, shoulder issues, sacroiliac joint, and many other topics. Ellen is

particularly regarded for the depth and specificity of her teaching. She also teaches

yoga group classes as well as individualized therapeutic yoga sessions at her New

York City yoga studio. Loren and Ellen, welcome.

Dr. Loren Fishman: Thank you. Tonight well be talking about yoga for lower back

pain. And the first thing Im going to do, of course, is I recommend you do with all

your patients and your students is to know that there are danger signs. I want you

to be aware of these because perhaps the most important thing you will ever do is

say to a patient, I cant help you. You got something very serious. Dont even put

on your leotard. Lets go to the hospital. Those signs are what we call the cauda

equina syndrome that every nurse or physician will understand immediately. The

danger signs are when there is ascending numbness (numbness starts in your feet,

it starts going up to your ankles and your calves), ascending weakness (the same

sort of trajectory), bowel and bladder changes (suddenly, Oops, my goodness, hes

wet!), or very severe pain. Very severe pain all by itself does not constitute cauda

equina syndrome, and you can probably over diagnose this much more than

underdiagnose this, but it is there. And when people are complaining of these

things, you must then recognize it is an emergency. You may be wrong. It may not

be cauda equina but to tell them that it is when it isnt, is far better than

telling them it isnt when it turns out to be. Its quite rare. A study shows its one in

a million in the population, but that doesnt mean you wont see it over the years. I

just want to point it out to you because you can save somebody not their life but

their happiness, their lifestyle. They become paraplegic, they lose control of their

bowel and bladder. Its not good.

Lets go on a little bit. When you see patients or clients (whatever you call these

people that have back pain), you can divide your pain into two categories very

easily. Is it acute? Are they coming to you because their friend said, Oh, I know

somebody who treats that, and no one else has seen it? Those are cases where

you have to make the diagnosis. Nobody knows what it is. It may be very deceptive.

It may be hip pain. It may be neuropathy. It could even be a terrible stomach ache,

honestly which makes their toes tingle. And it may get worse over time, a short

time, versus chronic which is what one is more comfortable seeing. Theres already

a diagnosis, you sometimes even know what works and what doesnt work, and the

whole thing is more or less predictable. They all have pain. Now whatever else pain

is, it raises awareness of itself and it lowers the persons concentration for

everything else including yoga, including talking to you. Once the yoga works a little

bit, they focus on it. They fasten on it like a leech. Theyre on there. They want

more yoga. In the beginning, though, its not that way. You have to gather their

attention by relieving their pain. To do that, the most important thing is to find out

what is wrong. In order to do that, you have symptoms like back pain, buttock pain,

sciatica, tingling, numbness, weakness.

Sciatica, all by itself, is not a diagnosis. Its a symptom like a rash. You got a rash,

but is it poison ivy, is it chicken pox, is it eczema; you dont know, you just know its

a rash. The same way with sciatica. You have pain down your leg, you know what

you feel, but what you dont know is, is it due to a herniated disc, is it due to spinal

stenosis, is it spondylolisthesis, is it piriformis syndrome? You really dont know. I

think thats one of the take-home points of what were saying today the same

symptoms may have several different causes.

Now here are the seven major causes. What does cause back pain? The rest of

what we talk about today and next week will be right here in these seven causes.

Dont write them down. Youll get sick of them by the time were done. Anyway,

here they are. I divide them up like this some are neurological, some are

musculoskeletal, some are a little bit of each.

Well start with the herniated disc, the famous herniated disc, and well go to spinal

stenosis. And then well leave the strictly, purely neurological diagnosis. So lets just

go ahead. The difference between the neurological and the musculoskeletal one is

big. In the neurological one, you have paraesthesia, numbness, sciatica, weakness,

and then this problem with the bowel and the bladder, and some atrophy where the

muscles get small. Now what is a paraesthesia? A paraesthesia is sort of the

opposite of numbness. Numbness is where you dont feel something thats there

someone touches you and you dont even know. Paraesthesia is the reverse. Its

where you do feel what isnt there. You feel pins and needles or hot and cold or

strain or burning, or stretching when theres nothing doing the stretching, no

needles. So these are the things you feel, and the order there is absolutely from the

least serious to the most serious.

Paraesthesia, this feeling something that is not there is the first sign or harbinger of

something thats wrong. By the time you get to numbness, theres no question

about it. Pain is next, and then weakness, where theres muscular debility and then

atrophy where the muscles are actually wasting away in the bowel and bladder.

Neurological, thats what it is.

Musculoskeletal has none of this, no paraesthesia, no numbness, no pain down the

leg, no weakness, and no atrophy or involvement of the bowel and bladder. Rather,

theres tenderness where you touch it or point. Theres an ache, usually, rather than

a sharp electric-type pain. And the movements are often painful. So thats the basic

thing. Now could movements be painful with something neurological? Yeah, I

suppose they could, but this is the picture that you usually see. You have to be

ready in this to just shift your focus and say, Well, maybe its this, but on the other

hand, I can make a picture for the opposite, too. This is cerebral work.

So now lets stick with the neurological. On the left, you see exactly what you saw

before. On the right, you see the kinds of things that can make it happen the

herniated disc, spinal stenosis, and spondylolisthesis, where one vertebra is slipped

forward on the one below it. Doesnt it sound like slip spon-listhesis, listhesis? The

non-neurological, on the other hand, nothing no sciatica, no numbness, no

paraesthesia, no weakness. Hurts to the touch, hurts to move, can be acute or

chronic. The idea is you have to pay attention to it because thats a huge group, but

were not starting there.

Lets start with the neurological. Lets talk about first a herniated disc. See the little

red circle there? Thats where it is. The pain usually emanates from that point

where the nerve comes out of the spine. Now is the pain there? Maybe yes, maybe

no. The pain may be way down there where that crosses in the middle of the calf,

that persons right leg. They may only feel that, even though the cause is way is up

high, the manifestation can be literally feet away.

What about spinal stenosis? Well, thats in the middle there, right in the spine. Once

again, though, the pain may be felt very far away, all the way down the course of

the sciatic nerve, or some other nerve.

Spondylolisthesis, thats the slippage of one spine on another and it can be on

almost any level in the spine.

Piriformis syndrome? Well, thats in the buttock where the nerve comes out. And

since its out there, theres almost always pain in the buttock even though it may

indeed go down the leg.

So those are the four big things that cause sciatica. If you put them all together,

you see all the different places that can cause back pain and sciatica. There are a

lot of them. Its hard to figure them out but here we go. How do you do it? Doctors

have ways that I want you to have, too. Theyre not so tough. All they demand is a

little common sense. They are the dermatomes and the myotomes. Tome means

cut in Latin. And so this is skin cuts and the muscle cut. Where do the distinctions

get made? Any questions at this point? Lets stop right here for a second.

Eva Norlyk Smith: I think clarifying spinal stenosis..

Dr. Loren Fishman: Good question. I didnt really say that, and thank you. Spinal

stenosis is narrowing of the spinal cord, the long vertical column from your brain all

the way down to wherever the nerves exit the spine. Well talk more about that

later. Thats a very good question. Well definitely go into that in much greater detail

than Im going into right now.

The dermatomes on the left there. Thats a very squat looking figure. Every part of

this body is served by a different nerve coming out of the spine at a different level

the front of the thigh there in brown, thats L2, the knee is L3, the inside of the

Calf is L4, the dorsal part of the foot or top of the foot L5, the outside of the calf S1.

Those Ls are for lumbar, the S for sacral.

Now over on the right You can study this at home. Its in so many medical books.

And why is it there? Because its so important. These are the reflexes and which

muscles are involved in which. The thigh muscle, corresponding to the brown area

there (but Im not talking about the skin, Im talking about the muscle), thats L2, 3,

4; the quadriceps, the outside of the calf, even though its S1 in the skin, its L4, L5

for the muscles there. The inside of the calf, even though its L4 for the skin, its L5,

S1 for the muscle. It gets confusing. These are things you really should know. And

there are reflexes corresponding. Someone doesnt have a good patellar reflex,

thats the quads, thats L2, 3, 4, thats in trouble. Person cant walk on their heels,

that means its the anterior tibialis at the outside of the calf. Thats L4. You can

learn so much without a stethoscope, without an x-ray machine.

Here are the more advanced medical tests that you may need, and you may actually

ask doctors to do this. If youre interested in having a practice that you take care of

the kind of patients that doctors take care of, you must refer the doctors. Then

theyll know who you are, and theyll refer to you. Theres the MRI which gives a

structural picture of the soft tissues. Unlike x-rays that pass right through those

tissues, the MRI delineates anything with a different density, a different consistency.

It goes in different angles or all kinds of special effects. Theres no x-rays, all

magnetic. They do it on little babies and women in the eight month of pregnancy

and the first month of pregnancy. The only trouble with it is you cant move. You

move, you ruin the whole show.

EMG, on the other hand, in the right-hand box, is functional instead of structural. It

tells us which nerves are working, how do they work, and how well do they work. It

talks about nerves and muscles. You can do all kinds of different positions. There

are special tests for people that only feel pain in certain positions and you can move

a lot when youre doing it so you can actually get a dynamic picture of what works

and when and why.

Herniated disc, what about it? Well, heres what it is. It has a discreet onset usually,

usually. That is, I went over to my aunts and I lifted her refrigerator, and thats

when she got it. I was in a small car for seven hours and when I got out, I could

hardly walk, thats when he got it. Theres often sciatica. There are often changes

in sensation and that involves the numbness and paraesthesias we spoke about.

Theres sometimes weakness, theres sometimes not. And it may or may not hurt in

the back. The cause is in the back, the manifestation may be way down the leg or

even in the foot.

Heres a picture of the spine way on the right and you can see my pathetic notions

to tell you which way that person is facing. Thats a little smiley pumpkin face up

there. The discs are in the front, the big bones associated with the vertebral column

are in the front, the nerves are in the back. You see where the neurological material

is? Its back further, and its protected. One of the functions of the spine (not its

only function), but one big function is to protect those precious nerves that are

coursing down through your body.

Now were cutting sideways, were taking a slice horizontally where that middle

arrow is emanating left on neurological which is slicing the spine and were taking a

look in there, a cross-section. A disc comes out from down below, from that gray

stuff below, and pushes upwards. The person is lying on their stomach and their

spine is sticking up in the air like the flaps of a dinosaurs back. This will press up.

Let me show you what the disc will do. It will press like that, right into the

neurological material. Or it will press off to the side, and catch one of those nerves

as it leaves the spine. Or it may do both.

What is it doing? Well, heres a cross-section of what they call a spinal unit, which is

two vertebrae and a disc and a nerve. And that red oval on the left gives you the

whole unit. Theres the nerve exiting. When the disc is herniated, it will press back

towards the nerves. Look at the figure on the right now. Thats a herniated disc

pressing against the nerve. The big yellow oval is the neuroforamen, the open

space surrounded mainly by bone. So if theres inflammation there, not much you

can do about it for that space to expand. Rather, it presses hard against the

vulnerable structures within the nerve. Heres a nice pose for that.

Ellen Saltonstall: So when the discs are herniated, you want to extend the spine

but very gently, and you want to make sure that you extend the spine with length.

So youre trying to make space between the vertebral segments, so that the disc

has room to have its proper place and not impinge on the nerves. So youre trying

to strengthen here your back muscles all the way up the spine from your head

through your upper back, through your lower back, and use the muscles to open

the front spine so that the disc can come back into its proper place.

Dr. Loren Fishman: I just want to add, in a pose like this, Salabhasana, the

Locust, youre also strengthening the muscles of the back, youre lifting your legs

and your arm and your torso and your head against gravity. So youre getting better

at doing this.

Ellen Saltonstall: And usually, the disc will herniate when theres excessive

forward bending, like especially when he mentioned lifting someones refrigerator.

Youre forward bending and putting an awful lot of force, a high degree of force into

the spine and so, the herniation happens usually in that situation. So youre

teaching the spine how to be in better posture for any activity by doing this kind of

pose. Its a mild pose, because you really only have to lift a little bit off the floor.

Youll see some more poses coming soon where you do a little bit more back bend.

But its really important, I think, for yoga teachers to know that you can do the

correct action in a very small way for someone who has been injured, or is

recovering from disc herniation, and they can do it safely and thereby establish the

proper habits in their musculature.

Dr. Loren Fishman: This is one of my favorite early poses because, first, because

the person isnt going to go any further than they can go without hurting

themselves.

Ellen Saltonstall: Its self-limiting.

Dr. Loren Fishman: And yet, theyre strengthening themselves and actually

preparing themselves for more difficult things. Its really pretty safe. Osteoporosis?

Thats okay. Spinal stenosis is the only thing that might be a little bit of a negative

here, but well get into that in a while.

Ellen Saltonstall: Here are two other back bending poses, both of them using the

arms, which will help to moderate the degree of back bend. You dont want to have

someone back bend too forcefully or in too much of a range of motion right away.

So with the Cobra, you notice that he has placed his hands a little bit wide apart,

which usually increases peoples awareness of lengthening the spine. Often in a

class, youll see people do Cobra with the hands really close in, and it does constrict

the ability of the back to extend quite a lot. So I recommend doing Cobra with the

hands wider, keeping the shoulders back, avoiding thrusting the neck back, and

making the curvature very, very even all the way up the spine.

On the right side, you see a modified Ustrasana so that the student has the support

of the chair, and can really work to lift the spine a lot. Generally, when you push

down with the part of the body like the arms and the legs in this case, then the

spine can lift. And thats really the curative action for herniated disc.

Dr. Loren Fishman: Now, theres a little trick here with the Camel Pose on the

right. By leaning back that way, you can get an arch. Some people think they can

get more arch by pushing their pubis forward, pushing their hips forward. But

actually, the way they usually try to do that is with their quadriceps. The trouble is

one of the quadriceps crosses the groin, so they cant do it that way. But a clever

way to do it is for a person to hook their feet across around the chair at the back or,

if theyre doing the regular Camel, to put their hands on their heels and push your

heels upwards so you use your hamstrings. And using your hamstrings will indeed

push your hips forward, and you get a much better pose. I wouldnt say it to a

beginner or one thats moderately into it. But as you get further into it, thats the

way to do the pose better.

Now were obviously going full bore. These are not simple things to do but theyre

wonderful things to do. These are more challenging. Let me show you how they

work as I put some slides in to show it. You can see Urdhva Dhanurasana, Up

Facing Dog, very well this way. Heres that herniated disc. We just talked about all

these poses. Heres the disc on the right there. You see its that part of the spinal

unit. On the left, it shows where it is. And theres that fluffy stuff pushed out of the

disc, pushed there and right where its not supposed to be close to the nerve. Well,

as you arch your back, you open up the front of the vertebrae. And like a bellow,

like opening a bellows, it draws that material back. It creates a partial vacuum and

draws that material back. Thats the way it works. Im doing it in a second, but it

may take several weeks or it may happen rather quickly. And thats the way this

pose works. Any questions now?

Eva Norlyk Smith: One modification that is often prescribed for people who have

problems with back bending like in Cobra Pose, Bhujangasana, (you had your pelvis

on a blanket), but one of the things thats often prescribed is to have your pelvis on

the blanket, but the pubic bone on the mat so that theres a little bit of a tilt to the

pelvis

Dr. Loren Fishman: Thats fine. One trick with that is, although its hard to do

this, but if you soften your abdomen (which I think that method would promote

because you feel hard against your pubic bone and that blanket will be soft against

your abdomen), so if you soften your abdomen, then your abdominal muscles arent

pulling you out of the extension, out of the arch of the back. So softening the

abdomen, its a little hard to do because youre protecting all your internal organs

when youre lying that way but it works very well.

Ellen Saltonstall: And softening the abdomen does make the back bend more

productive.

Eva Norlyk Smith: There was a study that came out showing that yoga seemed to

help with degenerative disc disease. They did MRIs with a group of people and the

yoga practitioners had less signs of degenerative disc disease. So would that

indicates that yoga could help prevent not just disc herniation and disc issues but

possibly also other chronic back pain issues that come from the gradual

deterioration of the intervertebral discs?

Dr. Loren Fishman: Yes, its wonderful. I mean, I think it has to be verified. I

think one study isnt enough because thats really important. That is big news.

Thats a regenerative feature of yoga. Thats magic itself. Thats the fountain of

youth, the Holy Grail. I mean thats some really good stuff. I read the study and it

just has to be duplicated once or twice and theres nothing like that. Thats really

good stuff.

On we go with the spinal stenosis. What is it? Heres what it is. Its where the cord

itself, the drawing on the right side of the left part of the slide shows you where the

cord ends. When youre a little baby, your spinal cord goes all the way down to your

coccyx. You can see it in the little arrows, CNS, central nervous system, ends here.

But as you grow, your vertebrae grow faster than your nerves and outstrip them, so

your nerves retract upwards, up to the spine. And little long cords come down,

which on the right you see theyre called, by some fanciful anatomists, the horses

tail, the cauda equine. And they do look that way. Those are the nerves. Where are

they traveling? Theyre traveling in a hollow column that starts at the brain and

goes all the way down to the coccyx. And that hollow column is what gets narrow in

spinal stenosis.

Heres a better view of it. Its a busy place. And when it gets narrow, its really hard

for all those nerves to get out there and they get irritated and all kinds of

inflammatory tissues and fluids arise there. And then theres pain. And when theres

extension, several cadaveric studies, mostly by PTs, show that extension will further

narrow the already narrow spine by more than fifty percent, up to sixty-three

percent. So if its already too narrow, extension is really not something you should

do. So Salabhasana, Kapotasana, Ustrasana, out of the question.

Now having said that, I have to make a caveat. About five percent of the time,

extension works for these people. I have a theory of how it works, but Im not

gonna tell you what it is yet. We have too many basic things that we do know to

talk about rather than to talk about speculative things. But about five percent of the

time, extension will work with spinal stenosis, and the same flexion will work with

herniated discs, exactly what otherwise doesnt work. So be tentative when you

start. Here are the poses that make sense for this. Look what a busy place it is.

Ellen Saltonstall: We have pictures of the various recommended poses here for

this spinal stenosis. In Downward Facing Dog, you can really stretch the spine

without diverting very much out of its neutral shape. In fact, you want to maintain

its neutral shape by arching your lower back, reaching your sitting bones up and

back, keeping the normal curves of the spine, while weight-bearing on the hands

and the feet. So its a very good strengthener and makes a good neutral position of

the spine that actually does a good elongation. And then in Vasisthasana youre on

your side. In the same way, the spine is in the neutral shape. Its not curving,

arching, twisting, and yet, its a very good strengthening pose.

Dr. Loren Fishman: In the pose on the right, I have to apologize a little bit. That

woman is actually countering scoliosis in there. Otherwise, she wouldnt be bulging

her left side ribs up that high.

Ellen Saltonstall: Here, we have a forward bend, Prasarita Padottanasana, and we

showed some modification so that its not too much of an extreme forward bend.

Im sure most of you yoga teachers know this already, but you can use a prop to

allow a person to extend the spine more truthfully while the legs are stretching.

Because many times, a beginner will be completely curved over in this pose, trying

desperately to reach the floor, trying to yank on their legs, and thats just really not

helpful in this kind of case. So you do use a prop to allow them to work more

honestly and really stretch the legs, really move the sitting bones back and extend

the spine. So I like to use the props and even instruct to lengthen the ribcage and

just really get as much length through the whole torso as possible. And then when

someone progresses, of course, they can go further down. You see the variation on

the right with the blocks.

Dr. Loren Fishman: Theyre like training wheels on a bike. And when the child is

ready, you just take the wheels off and they ride away. These blocks and all of

these paraphernalia need not be there when you get pretty good at it. But how

many herniated discs have I seen and people fiercely and desperately grasping their

ankles and pulling for all their worth, pitting their muscular strength against their

stiffness, and nobody wins.

I just want to tell you something about Vasisthasana that you may not know. This is

an MRI of a person that has a herniated disk and spinal stenosis which you can see

pretty well down low in the spine. This is that same person. Look down at L4, L5.

Look how the whole vertebral column slid to the left and look at that disc pressing

against the white stuff which is where the nerves are, absolutely occluding the

white stuff there at the same level. And here they are in Vasisthasana. Where is it?

Wheres the spinal stenosis? Wheres the spondylolisthesis? Wheres the herniated

disc?

Heres looking at it cross section. Right in the middle there, you can see theres a

little tiny space, sort of a triangular space. Thats where the nerves are supposed to

fit. Now here is the same person, a minute later in Vasisthasana. See the

difference? Here they are not in Vasisthasana, and here they are in Vasisthasana.

Its amazing. There are a number of poses that are good.

Now well go on and talk about musculoskeletal illnesses. This is a great big vast

section. It goes on and on. Well just talk about a few of them. I said the most

important thing in my opinion already which, is look and see. You dont know what

it is until you look. And you will never see if you dont look.

Ellen Saltonstall: Posture makes a difference. You can see lots of different

variables of postures, so its good to be able to see clearly your students, what kind

of spinal posture they have. You can see the ideal posture in the middle and on the

left and on the right slide, to the far left. You want to look do they have too much

curvature in the upper back, too much curvature in the lower back, no curvature

anywhere and all kinds of deviations left and right. So thats really important to

know about your spine if youre doing yoga and your students spine.

Dr. Loren Fishman: Now here, lets compare again and say if its spinal stenosis or

a herniated disc or spondylolisthesis where the spine is slid over, then if its

neurological. If its musculoskeletal (these are just three of the many candidates), it

could me muscle spasm, it could be sacroiliac joint derangement, or a facet

syndrome. When its musculoskeletal, remember, theres no numbness, no

weakness, no pain that goes down the leg, no atrophy, theres no bowel or bladder

involvement. There is tenderness. Theres some place you can press and the person

will go, Thats it. Youre not just being a brute. Youre getting to the spot where

the pain comes from. There will be aches, most likely, some movement or other will

be painful. Its eighty percent of all back pain. It is second in days of work missed

only to the common cold. And it is often spasm in relation to strain.

Many forms of spasm.. Lets just start with the one which I think is very common

the quadratus lumborum, that large quadrangular muscle that starts at the ribs

and goes down to the iliac crest. It gets tight. Ellen showed you in those profiles

where the back is too arched many children carrying their book bags, many adults

who just wear high heels too often, or its just their posture. Women, when theyre

carrying their baby, often will have very tight muscles there.

Ellen Saltonstall: These are all forward bends, obviously. Three out of four of

them have the arms forward. When you do that, you catch another muscle,

latissimus dorsi, which goes from the top of your arm all the way down to your

waistline and into the top of your pelvis. So you need to stretch all the way down

the back because the lumbosacral fascia, the tough coating of the muscles down in

the lower back, is very very tough. It takes some time to stretch. So these poses

would not be appropriate for someone with a herniated disc. And probably not for

someone with stenosis, either. But they are appropriate if you know that the

problem comes from muscular spasm.

We have Janu Shirshasana. We have Childs Pose, simple Childs Pose with head

resting on the hands. We have Triang Mukha Ekapada Pashimottanasana on the

lower left, and then a version of Malasana on the far right lower corner. I really like

this one for clients that I see because many people cannot do a seated forward

bend, or perhaps they cant even do Childs Pose because they have problems with

their knees. So Malasana on a chair is very good because you dont require much

stretch of the hamstrings, a little bit but not very much And you get a major stretch

of the lumbosacral fascia, a major stretch of the latissimus dorsi, the quadratus

lumborum, and all the vertical spinal muscles, the erector spinae muscles that go up

the spine. So its very, very good for spasm.

Dr. Loren Fishman: I just want to say, can you see how to use this? If somebody

comes to you and says their back really hurts, you find out they dont have any

numbness, they dont have any tingling, they dont have any pain going down the

leg, theyre not weak, they dont have any bowel/bladder problems, the muscles

look altogether symmetrical, then its time to start these. You may not want to go

full bore all this far, but you may want to start with this. Start with one of these,

start with Janu Shirshasana and see if it helps a little.

Ellen Saltonstall: Well show you some easier variations of some of these, too,

that are coming along.

Dr. Loren Fishman: I mean, you could figure out there are easier versions. You

just do them halfway or a quarter and then you go further. Show them you care

and they will focus on your care, and focus on what you care about, which is them.

At times, a form of arthritis is facet syndrome, the joint that has really gotten out of

kilter. They sometimes call it the mulberry joint because it looks like a boiling up

mulberry. At times, its just spasm. You do an x-ray, you do an MRI, you do all the

fancy things, you dont see a darn thing, because the muscle is tight. And what do

you do for that? Well, what happens in this case, in either case, whether its arthritis

that crimps the joint from moving, or its a spasm that holds the joint fast so it

cannot budge, in either case, you want to work with it, you want to get that joint to

move.

Here is the mulberry on the right. On the left is a normal spinal unit. Theres that

little facet joint right in the middle there, slipping and sliding. But on the right,

theres arthritis. Theres a bump on the road. It doesnt move that way. Theres

speed bumps all over the place. So what do you do?

Well, let me explain just briefly that all the different levels of the spine, they all have

facet joints. But in each case, theyre different. Never mind the atlas and the axis,

theyre unique unto themselves, the same with T12, L1. But in the cervical spine,

theyre sort of stretched out like someone blessing a population. In the thoracic

spine, theyre kind of as though youre holding a stop sign. Theyre up quite high in

the air. And in the lumbar spine, theyre as though youre trying to cut something,

like raise your palm up and point it so your palm is facing to the left. Thats the way

those joints look, like shaking hands straight out. And in each case, their

movements are defined by the position of the facets. Thats very important to know,

and I encourage you to study. We cant into it right here, but its really interesting.

Now here are the poses that work whether its arthritis or a tight muscle, either

case, here are the guys thatll do it.

Ellen Saltonstall: Supta Padangusthasana is a wonderful pose to work with for

any kind of lower back pain thats musculoskeletal because the hamstring is a very

strong muscle that tends to pull the lower back into flexion. It tends to round the

lower back when its tight. So to stretch it with the back safely on a flat position on

the floor, is so good because it really allows a freedom of movement between the

hips and the lumbar spine thats very healthy for daily life, and especially for any

kind of work like lifting things.

So youll notice in both these pictures, theres a blanket under the spine here which

will create that slight bit of anterior tilt in the pelvis, raising the top part of the

pelvis up slightly, and the bottom part of the pelvis where the sitting bones will be

lower on the floor. Thats an anterior tilt of the pelvis which situates the pelvis very

well for stretching the hamstring. The hamstring attaches at the sitting bones and

then goes up to a place above the knee, in this case above because the leg is

vertical. And then youre stretching that entire muscular structure plus the calf

muscle and even into the foot.

On the left-hand side, you see the second leg is bent which will be easier for

beginners. It will help them not to cheat so much. It will help them be more honest

with the pose and get the knee straight of the stretching leg. Then when you can

accomplish it, you want to have the other leg pressing into the floor to stabilize that

tilt of the pelvis, to make sure that the pelvis is properly positioned to maximize the

stretch on the leg that youre working with which in this case is the right leg.

Dr. Loren Fishman: Notice here that the long leg thats elevated, its like a lever.

The hip joint is not situated at the back of the body. The hip joint which is the

fulcrum here, is a couple of inches up from the floor. So when the person pulls on

the foot the way that you see it in both of these pictures, theyre using it as a lever

to stretch the fascia in the lower back, the muscles in the lower back, and moves

those facet joints. Once theyre moved, the pain often goes away just like that.

Ellen Saltonstall: So this is curative in itself, but its also preventative of the kinds

of danger things that can happen when youre moving around with tight hamstrings

in your life.

Supta Padangusthasana, too, is taking the leg out to the side. We showed two

different slides and we included two slides because the left-hand one has that nice

little sand bag, holding the left thigh down. So thats the leg thats not in the so-

called stretch, but its a very important part of the stretch because it stabilizes the

rest of the body. If you take your leg out to the side without that stabilization, then

youll be torqueing your lumbar spine which could bring on other risks. So the

stabilization of that straight leg thats down will make the pose safer for the lower

back. And then you see on the right-hand side, the person doing the pose without

that sandbag and actually using his own strength to keep the thigh down.

Dr. Loren Fishman: Just what Mr. Iyengar does in Light On Yoga. I would like to

invite you to try this. And once you get into position, the straight leg thats going

straight down, the stabilizing leg, stretch the heel out, and you will feel the different

facets in your back move. This is a wonderful pose for facet syndrome. It doesnt

hurt them, but it moves that exact tissue you want to move, the little facet joints.

Get into position first then stretch your heel like pointing your toe. Dont point your

toe. Point your heel.

Heres one that will obviously help with the facet joint. But is it always as good as

Supta Padangusthasana II? You can see what this does to the facet joint in both

pictures, actually, on the right. You can see there are many versions of this, and

each of them will do it to a different extent. You might want to start with the way it

looks on the right and move to the one on the left.

Ellen Saltonstall: The one on the right, obviously her hand is not down on her

leg, so shes not bending as far to the side. This will be a very safe way to start.

Shes got her foot stabilized against a block, against the chair. Shes got the support

of the chair so that she doesnt go too far. And then she doesnt have her other arm

raised up, so its a milder version. Then on the left, you see a more intense version,

but she still has support of the wall which I think is so important. When youre

dealing with someone in pain, theyll do a much more accurate job of their yoga

poses if they have a little bit of support, especially in the beginning. So shell be

able to bend to the side more clearly and accurately. We all tend to want to go

forward when we bend to the side because it actually makes the movement feel like

its going further. A little bit of forward bend in these poses is okay, but in order to

get to the side bend, the wall is just so helpful because its a reference point and a

stabilizer.

Dr. Loren Fishman: The other point about using the wall is if you dont, when

balance is an issue, all kinds of extra muscles come into play. The abdominal

muscles get tight. The muscles of the arms start to regulate how your torso is

moving. And the tighter the muscles get, the less motion youll get. The less motion

you get, the less chance of moving that facet thats in trouble. So support is good

here.

Ellen Saltonstall: Now we have two beautiful twisting poses, both of which are

quite challenging. But you can work towards them step by step. The pose on the

left, Pavrita Janu Shirshasana, pose on the right is Pavitra Ardha Chandrasana. So

the pose on the right is a deeper side bend, obviously, because youre bending over

your extended leg. So this one you can approach very gradually, by first going a

little bit forward and twisting the spine. Obviously many people will not be able to

reach both their hands to touch the foot like this beautiful demonstration does. But

in any case, it can be a very effective side bending pose. Then the twisted Ardha

Chandrasana obviously will move the facets in a good way. This is not an extreme

side bend or even forward bend, so its a really good way to get the spinal

segments to move.

Dr. Loren Fishman: I look at this one more as preventative, both of them. Theyre

pretty hard when youre in the position, but if you dont want to get this happening

and you love these poses, its a good way to prevent facet syndrome or segmental

stability.

Now lets talk about another kind of back pain, musculoskeletal in its origins. Its a

completely different flavor. It first get the name from people getting a Harrington

Rod for scoliosis and thats not very common. But the back gets too flat. If you

recall if youve been in a museum and seen an old Henry Ford shock absorber, its a

curved piece of steel. And because its curved, it bends further when the car goes

over a bump. Its a long curve that goes from the front wheels to the back wheels.

Well, thats the way the spine works, too. If it has no curve, then it has no ability to

to absorb any kind of sideward pressure. Up and down pressure is zero. So the

point of this is that when the back is curved a little, it is a much more versatile

instrument.

The pain that you get in this kind of syndrome is partially due to that, that you have

very little flexibility. But its also due to the fact that when you do have flexibility,

the muscles get tight. And the tighter it gets, the more it hurts. And the more it

hurts, the tighter it gets. Its a closed box. Its a terrible position to be in, and you

see the people in it almost every day.

The muscles that are involved, Ill show you on the next slide, its really pretty

gruesome. Its everywhere. That lumbosacral fascia is being pulled. Its tough. Its

richly invested with nerves. It cant move and it cant stay still that way for very

long because it hurts too much. All kinds of muscle, the semispinalis, the capitis and

not capitis muscles, the serratus posterior inferior where the upward diagonal

arrows are, the transversalis or transversus abdominus where the horizontal arrows

are, and the gluteus maximus where the diagonals are all pulling on that same

sensitive structure, not good.

So what do you do? Theres plenty of things to do. Weve already talked about Janu

Shirshasana and Pavrita Janu Shirshasana which will take the lumbar fascia one side

at a time. Very often, you need to use poses that will prepare you for those two, for

the twist of Ardha Matsyendrasana and Pavrita Trikonasana. Lets go through a few

of them.

Ellen Saltonstall: Here are two modified versions of Janu Shirshasana that are

excellent, really excellent for stretching the lower back. Using the chair allows

people to go into a higher version which will still give a good stretch without

straining too far down into the lumbar vertebra. We show it here with the chair,

head resting on the chair, arms reaching up the back of the chair, and then with the

belt. These are two classic ways to practice Janu Shirshasana.

Dr. Loren Fishman: Notice the back stays straight. I mean, if you have

osteoporosis, you can still do these poses. Youre stretching the back just enough.

This is the misnamed Janu Shirshasana. Misnamed because you dont really bring

your head to your knee. You really bring your belly button to your thigh. You come

forward, not down. Then the Pavrita Janu Shirshasana you can see on the right also

the head is not at the knee. Nevertheless, its an excellent pose for the flat back,

because it takes the lumbar fascia one side at a time, the old Roman strategy

divide and conquer.

Ellen Saltonstall: We have two moderate poses, one weve already looked at, the

one on the right, Malasana, which is very, very good for stretching the lumbosacral

muscles and the gluteal muscles all of which contribute to flat back. I have many

clients where this is just such an effective pose. Then the twist on the left, this also

is a really good pose for the facet syndrome people, too, because youre moving the

different segments of the spine such that all the muscles involved will be stretched

the transversalis and all the muscles that go up the spine. Everything is loosened

by this very simple twisting pose. And people can do it with their clothes on. They

can do it in their office, at their desk.

Dr. Loren Fishman: Its really a nice way to do it. Then we have Ardha

Matsyendrasana and Pavrita Trikonasana, both of which obviously will stretch the

lumbar fascia. I hope its pretty obvious. Theyre more advanced. You couldnt start

here with people but you get here. I find when I treat people that have this with

yoga, it often takes me up to an hour to get them better. You just have to get them

lose enough and they have to get confidence in you. And they have to get the

opposite, too. You have to be able to show your humility. And the way you do it in

my opinion is to say, Is this better? Do you have any effect with this? Keep

communication with them. Otherwise, they go right back to spinning into the orbit

that made them in pain in the first place.

Ellen Saltonstall: In both of these, you can see clearly that the spine is elongated

and the head is in line with the pelvis. So its really important with twists. And this

is, of course, true for osteoporosis, as well, to keep the spine long and to keep

shoulders level and to keep the head in line with the pelvis. Because otherwise, you

might be causing more trouble while youre getting more mobility into the spine. So

both of these twists are very basic and can be modified. You can see on the left, the

person is sitting up on a blanket. You can even sit up higher, you can sit up on a

block or even a chair to practice this pose which will make it easier for a beginner.

In the pose on the right, Pavrita Trikonasana, shes got a block, but you could even

use two blocks. You can make the pose much milder at first to have the student

understand really what the twist is, how to keep the spine long, how to keep the

head and the pelvis in one long line.

Now we have this more compete version of each pose. She doesnt have extra

props. Shes doing a deeper twist with her elbow to knee on the left-hand slide, and

0then shes leaning against the wall on the right-hand slide which is a very good

way to practice Pavrita Trikonasana. It gives confidence to people when theyre

doing this difficult pose. This pose requires a lot of stretch of the gluteal muscles

and that can be almost a shock to people if they havent practiced it much, how

much it demands of the legs when its really You know, you think of it, Oh, this is

the spinal twist, but it really demands a lot of the leg.

Dr. Loren Fishman: The way you start the Pavrita Trikonasana is by facing the

wall, and then you twist around like this. Its an excellent way to do it. And again,

the stability of the wall helps a lot. And the wall is a very good teacher its

consistence and confidential.

Eva Norlyk Smith: Loren, I just want to make sure we have enough time for

questions.

Dr. Loren Fishman: Lets stop right here for the night and have questions.

Eva Norlyk Smith: Good, because we got quite a few questions. Shelly from is

saying, Much of the current research in pain science shows that damage or

changes to the spine actually has a poor correlation to low back pain. What do you

think about this and how does that influence the way we address our treatment

approach? So that was, I think what you were addressing about with the muscle

spasms

Dr. Loren Fishman: The first study done like this was done at Harvard by a

woman named Maureen Jensen, and she took a hundred people. All they had to do

to be in her study was never have back pain. She did MRIs on all hundred of them.

Thirty-three of them had whopping pathologies or significant pathologies. This is a

well-known thing. However, you cannot conclude from that all the things you see on

an MRI are worthless. Its a question of clinical judgment and its a tough one. The

more doctors the patient has seen, by the time they see you, the harder its gonna

be and the easier its gonna be. It will be easier because theyve already made a lot

of blunders. It will be harder because this is a difficult case or they wouldnt be

there before you.

Everything youre hearing tonight, you get out that salt shaker, take it with a grain

of salt. Because as I said, five percent of whats supposed to be one way is the

other. Five percent of spinal stenosis responds to extension. Five percent of a

herniated disc will do better with flexion, for example. All the way through, theres

more here than weve dreamt of in our philosophies or our medicine. There really is.

Its true. Nevertheless, theres something thats wrong and there is a cause. It just

isnt always easy to find it. One more thing to say In many cases in medicine

today, the technology is better than the doctor. Technology gives you an

embarrassment of riches. You can make five diagnoses, probably only one of them

is the main pain generator. Thats the problem that that study turned up and its

something I think well-known to a lot of experienced people.

Eva Norlyk Smith: Lori from Fairfax in California says, When I have an acute

strain, stretching often feels good initially but then hurts when I finish. Should I wait

a while until it settles down?

Dr. Loren Fishman: If it really is a strain, the best thing to do is just to rest it.

Then you will get stiff. And when you get stiff, then you stretch a little bit. The way

the histology works is that when you do a strain, then inflammatory cells rush in not

just to give you grief, they also rush in in order to lay down new collagen fibers and

begin the repair, and heal whatever it is thats not right. And in the course of doing

that, they make it stiff which is a physiological stiffness. Youre stiff because if you

start to stretch it, youll pull out all the work that these good cells are doing. So then

if you wait, I would say ten days, but Id really say three weeks, heres what

happens. After almost immediately, within a day or two, a double strand of collagen

will form in any injury to a connective tissue, like DNA, its a double strand. Its like

first aid. Then three weeks later, almost to the day, the double strand will start to

dissolve and a triple helix will form. Its like braiding a girls hair. And when you get

that, that will be the permanent structure. All the molecules in there will be

exchanged, the structure will remain from then on until you tear it again. So at that

day, twenty-one or so, thats when youre vulnerable again, because the one thing

thats been holding it in, the double helix, is dissolving and the triple helix hasnt yet

formed. So I would say when you have a real sprain, wait a couple weeks. Take it

easy. And then after four weeks or three and a half weeks, then you start to work

very tentatively, very mindfully, until youre back where you started from. No

medicines, no surgery but patience and knowledge of whats going on.

Eva Norlyk Smith: Dan from Oakland is asking, In twisting postures, do you

prefer stabilizing the pelvis or allowing the pelvis to turn in the direction of the

twist?

Ellen Saltonstall: I much prefer stabilizing the pelvis so that the twist starts in a

minor way in the lumbar spine which doesnt actually have much potential to twist,

and then further up, you twist it even more the further up the spine you go. The

reason I like that better is that I believe that when you twist the pelvis, theres a lot

more chance of error, theres a lot more chance of torqueing the sacroiliac joint and

theres a lot more chance of actually spraining your hip joint. I think twisting with a

stabilized pelvis is better.

Dr. Loren Fishman: I totally agree with Ellen, but I have to add (and she probably

would, too) that if the pelvis moves, its like safety valve. It may mean that youve

gone too far for you at that time. So if it moves a little bit, be patient with yourself.

Understand whats going on and why. Thats really the essence of it. Its surely

better to keep this pelvis stable. Thats the whole point of the pose is to twist. And

when the pelvis moves, you twist less.

Eva Norlyk Smith: Then the last question is for Ellen. Ellen mentioned that chair

malasana is not appropriate for stenosis. Can you please explain why? Thank you.

Ellen Saltonstall: Well, as Loren explained, extension will narrow the spinal canal.

Its really something to test out and see if your pain is helped by it. Its one of those

things where you have to try it. If your pain is helped by forward bending, you start

very gently leaning against the chair and then going down to the floor. I would go

just little by little test it out.

Dr. Loren Fishman: It might really be good for spinal stenosis but its not

something to do with a herniated disc. You shouldnt do flexion like that with a

herniated disc because youre likely to extend and make the disc worse. With a

herniated disc, you do extensions. With a spinal stenosis, you do flexion. But five

percent of the time, its the other way around. This is life.

Eva Norlyk Smith: So we wanted to thank everyone, for joining us tonight. And

we also wanted to extend a special thank you to Loren and Ellen. Obviously, back

pain is a vast subject, and were really pleased, Loren and Ellen, that you joined us

to share your experiences.