Therapeutic Application of Iyengar Yoga for Healing Chronic Low Back Pain
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INTERNATIONAL JOURNAL OF YOGA THERAPY — No. 13 (2003) 55
Therapeutic Application of Iyengar Yoga for
Healing Chronic Low Back Pain
Kimberly Williams, Ph.D., Lois Steinberg, Ph.D., and John Petronis, M.S.
Abstract Alternative Medicine (CAM).3 In India, however, Yoga
Low back pain is a significant public health problem is not an alternative healing system but a part of main-
that has reached epidemic proportions. It places a sub- stream medicine. In either case, this therapeutic applica-
stantial burden on the workforce and the health care sys- tion of Yoga requires the classical postures to be adapted
tem.1 It has proven very difficult to treat, and it is one of to address the specific problems associated with each
the most commonly reported reasons for the use of com- medical condition.
plementary and alternative medicine.2 Many different Many different methods of Yoga exist and each has
methods of Yoga exist and each has its own technique for its own technique for preventing and treating disease. The
preventing and treating disease. This article describes most common methods of Yoga therapy in the US are the
the rationale and method for the therapeutic application Iyengar method, Viniyoga, Integrative Yoga Therapy, and
of Iyengar Yoga for chronic low back pain. Preliminary Phoenix Rising Yoga Therapy. The Iyengar method is
results are also presented from a pilot study evaluating based on the teachings of the Yoga master B. K. S. Iyen-
the efficacy of a 16-week program of Iyengar Yoga ther- gar, author of the classics Light on Yoga4 and Light on
apy in persons with non-specific chronic low back pain. Pranayama.5 Iyengar’s teachings are deeply grounded in
the ancient Yoga tradition, and his intense personal prac-
Introduction tice and more than 60 years of teaching have produced
significant innovations. Among the most noteworthy are:
Yoga is a 5,000-year-old tradition whose classical 1) an emphasis on standing poses to develop strength, sta-
aim is liberation from suffering in this life. Ancient texts bility, stamina, concentration, and body alignment, 2) the
make it clear that mental and physical illness or lack of use of props to facilitate learning and to adjust poses for
health are impediments to this goal. Yoga was used in those who are inflexible, and 3) instruction on how to use
antiquity to overcome these impediments in preparation Yoga to ease various ailments and stress.
for attaining the goal of self-realization and liberation His system is based on the eight constituents of
from suffering. Although the ancient seers recognized Patanjali’s Astanga-Yoga that lead to self-realization and
the health and healing effects of Yoga, they were not the liberation. They include yama, niyama, âsana, prânâ-
primary goal of practice as is the case in America today. yâma, pratyâhâra, dhârâna, dhyâna, and samâdhi. Most
Yoga is now regarded in the West as a holistic approach schools of Yoga practice each limb separately using
to health and recently has been classified by the National âsana as preparation for meditation. Iyengar’s unique
Institutes of Health as a form of Complementary and contribution has been the realization that all limbs may be56 INTERNATIONAL JOURNAL OF YOGA THERAPY — No. 13 (2003)
practiced and integrated into âsana Reasons for Implementing body position and movement in the
and prânâyâma. Therapeutic Yoga for Low postures. These props also help
The therapeutic application of immobilize joints so that specific
Back Pain
Iyengar Yoga has been used in med- areas are targeted. They also provide
ical settings6,7 and in Yoga centers by Although the regular practice of controlled traction, which assists
teachers having Junior Intermediate Iyengar Yoga is viewed to be healing active or passive forms of movement
III or higher certification. and health retaining,8,9 there are sev- depending on the pose and the
This paper will describe the ther- eral reasons for implementing a ther- capacity of the student. It is the ulti-
apeutic application of Iyengar Yoga apeutic version of Yoga for someone mate goal of Yoga therapy to enable
for treatment of chronic low back with LBP. Classical postures require a student to attain a healthy back free
pain, the rationale behind the effort and skill to be health enhanc- from LBP. The teacher assists the
method, and preliminary findings student to transition from supported
from a pilot study evaluating the poses to the execution of classical
efficacy of a 16-week program with Iyengar’s system is based poses without support. Practice of
ambulatory adults with chronic low on the eight constituents the classical postures furthers the
back pain. of Patanjali’s Astanga- student’s awareness of latent imbal-
ances and requires mastery of cor-
Yoga that lead to self- rective movements.
The Goal of Yoga Therapy realization and liberation.
for Low Back Pain The Evaluation Procedure
ing and therapeutic, whereas an indi-
The primary goal of Yoga ther- vidual in pain requires the injured Iyengar Yoga therapy begins
apy for low back pain (LBP) is the area to rest prior to introducing cor- with an evaluation of an individual’s
relief of pain and functional limita- rective action. It also takes time to known medical history for possible
tion caused by a chronic lower back develop the awareness and neuro- causes of pain followed by a diag-
disorder. This is achieved by mini- muscular coordination to perform the nostic examination of the student.
mizing, healing, and ultimately cor- poses in a way that corrects imbal- The instructor performs this initial
recting underlying physical mal- ances contributing to LBP. In addi- examination as the student performs
functions through a series of anatom- tion, Yoga therapy relies much more tâdâsana (mountain pose), a basic
ically correct postures. Unlike most on external support through the use of standing pose that permits the
conventional medical treatments that props. This external support enables instructor to look for signs of dys-
focus on treating LBP symptoms the student to rest the injured area function and imbalance in specific
through medications and surgical and achieve correct postural align- regions of the body such as the feet,
procedures, Yoga therapy works to ment and movement in the postures. legs, knees, hips, torso, chest, shoul-
correct underlying internal malfunc- Specific body positioning for ders, neck, head, and carriage, and
tions that contribute to mechanical each Yoga posture opens and creates how these dysfunctions affect pos-
causes of non-specific LBP. It is space longitudinally, horizontally, ture, levelness of the pelvic girdle,
through the process of helping peo- and circumferentially without aggra- alignment of the spinal vertebrae,
ple with LBP to rest the area of pain vating injured areas. Iyengar Yoga is and gait. Attention is paid to the
and then educating them in proper noteworthy because this particular alignment of bones and pelvis, mus-
alignment of bones, muscles, and method incorporates props such as cle tone, and the tightness, hardness,
connective tissue and movements ropes, benches, bolsters, blankets, or color of the skin for signs of mus-
that the healing occurs and changes weights, straps, blocks, and other cle imbalance and poor circulation.
the underlying root cause of the dis- devices to provide support during The Yoga instructor continues to
comfort. The practice of Yoga is performance of the postures. Props gain insight into the biomechanical
designed to educate students in the are useful for facilitating rest and causes of LBP from observing per-
use of a daily regimen of self-care relaxation, avoiding unnecessary formance of the postures. Areas of
that acts to manage and ultimately strain, revealing latent muscle tightness and hyperflexibility that
prevent the recurrence of chronic strains, inflammation, or restrictions create imbalances in the muscu-
LBP through healthy postural and due to stiffness or injury, and for loskeletal system are exposed. The
movement patterns. helping the student achieve correct instructor is particularly interested inINTERNATIONAL JOURNAL OF YOGA THERAPY — No. 13 (2003) 57
evaluating a student’s limitation of such as prone supta-pâdân- the mind-body nature of Yoga that
movement in several directions gushthâsana (supine foot–big toe emphasizes awareness, concentra-
according to the person’s height, pose), should ideally be done for up tion, and bidirectional communica-
weight, flexibility, and lifestyle to five minutes to reduce inflamma- tion between the mental, nervous,
(sedentary vs. active). In most stu- tion, achieve optimal length of the skeletal, and muscular systems.
dents, dysfunction occurs due to joint, muscle, and connective tissue, Yoga is not a passive activity
either stiffness in the lower back and to optimize retraining of mus- that simply occurs by itself; it
muscles or tightness in the hips, cles. When mobility is the goal, instead requires an active mind and
quadriceps, hamstrings, groin, or
thoracic spine. Such stiffness or
tightness leads to difficulties in
All postures must be performed in a consciously
spinal and pelvic rotation, lateral aware manner that is fully appreciative of the intri-
bending, and forward or backward cacy of each movement.
extension. Unlike many traditional
physical therapy rehabilitative exer- more active stretching is involved body integration to assure the
cises that focus primarily on defi- and poses are held for short time anatomically correct pose occurs
ciencies in flexion or extension, periods (15–20 seconds) and re- that stimulates all muscles and tis-
therapeutic Iyengar Yoga works to peated up to 8 times so that soreness sues to achieve proper alignment,
enhance alignment, flexibility, mo- does not develop from strain or over- strengthening, flexibility, stability,
bility, and stability in all muscles and stretching in beginners. Once mobil- and physiological function of the
joints that affect spinal alignment ity is achieved, the student is surrounding tissues and organs. The
and posture.10 instructed to stay longer in the pose intricacy that occurs allows practi-
(1–2 minutes) with less repetition tioners to stay in the pose for longer
Structuring the Therapy according to their capacity to regain periods of time, at first with effort.
proper anatomical alignment, flexi- As they practice and progress, they
The Iyengar principles of bility, and strength. can remain in the pose with a light-
sequencing, timing, and intricacy of Finally, all postures must be per- ness and ease. Sustaining the posture
poses provide a framework for thera- formed in a consciously aware man- in a dynamic state permits positive
peutic instructors to structure the ner that is fully appreciative of the physical and psychological changes
progression and content of therapy.11 intricacy of each adjustment, to occur, and intricacy is thus central
Sequencing refers to the deliberate appraising, quantifying, and qualify- to the healing of musculoskeletal
progression of postures selected by an ing movements to obtain proper imbalances. Maintaining a number
instructor to specifically target a alignment in the pose. B. K. S. Iyen- of opposing muscular movements
group of muscles, with variations of gar noted that many beginning Yoga creates internal traction that length-
postures that gradually release muscle students have difficulty monitoring ens constricted muscles and connec-
tension, open up joint spaces, increase simultaneous contractions that must tive tissue and increases disc and
circulation, and decrease inflamma- necessarily occur in multiple mus- joint space.
tion. It also refers to the order in cles groups to assure that a pose is
which students are asked in more performed to achieve the optimal The Setting
active poses to engage various muscle therapeutic effect. For instance, in
groups to achieve the correct align- the fundamental position tâdâsana Iyengar Yoga instructors work
ment and movement in the postures. (mountain pose) students are asked either individually or in a classroom
Timing refers to the length of to move their frontal thighs back- setting with each student to create a
time each pose or âsana is held, ward and their outer thighs inward, series of postures to perform at each
depending on the capacity of the stu- simultaneously. Cognitive aware- session that are most beneficial for
dent, to optimize the release of ten- ness and control are required to each individual and that are prac-
sion and “opening” of joints while insure that proper physical position- ticed in a manner that minimizes
minimizing pain. Iyengar philoso- ing occurs when many simultaneous potential harm to the student. A typi-
phy posits that passive weighted and often opposing actions are to be cal therapy session will start with
poses, such as prone shavâsana performed in a posture. These move- several passive postures that are
(corpse pose) and tractioned poses, ments are “intricate” and highlight variations of a selected movement58 INTERNATIONAL JOURNAL OF YOGA THERAPY — No. 13 (2003)
(e.g., groin extension or hip opener) decrease inflammation. It is impor- back with the help of the teacher.
and move toward postures that the tant for the muscles to release and These passive postures are fol-
student must work actively to return to their normal position rela- lowed by supported postures involv-
achieve involving countering the tive to tissues, bones, and organs ing more active stretching. This is
force of gravity. The end of a session prior to a more active phase of cor- achieved by providing traction in
is concluded with passive postures to recting underlying imbalances. these postures by the gentle physical
quiet the mind and relax the body. As External props such as plate weights adjustment of an instructor, and by
the student progresses, the passive and sandbags in conjunction with the use of external props such as wall
postures at the beginning of the ses- gravity are used to encourage tight ropes, benches, trestle, and gravity.
sion are eliminated. muscles and tissues to relax. Gravity is a powerful force that is
Besides providing rest to the used to release muscular tension
The Method injured area, the passive postures (sandbags, weights as noted above)
impose a gentle lengthening of tight and to create extension in the spine.
The Iyengar method of Yoga or inflexible areas and begin realign- This is initially provided through
therapy for LBP targets a number of ing imbalanced areas and increase external support but is ultimately
areas in the body by using a series of created by forces in the body of the
postures from all categories of poses skilled student, which counter the
to address imbalances in those The more active correc- force of gravity.
areas.12 Postures are structured to tive phase of Yoga is As back pain mitigates and flex-
work peripherally from the injury consistent with current ibility, strength, and postural align-
site. The initial poses address gross ment improve, instructors guide
or superficial layers of the imbalance sports medicine ap- students through postures that chal-
or misalignment. These are followed proaches to LBP therapy. lenge the back. The more active cor-
by more challenging poses that rective phase of Yoga is consistent
affect deeper or more subtle mis- flexibility in joints, connective tis- with current sports medicine
alignments. Each pose in a sequence sues, and muscles. approaches to LBP therapy in which
adds to students’ understanding of Passive postures also enable the patients must actively treat the low
the imbalance and teaches students learning of different actions in poses back pain through physical work that
how to correctly align and work their by students prior to their attempt to initially causes discomfort but
musculoskeletal system. practice the more demanding stand- reduces pain relative to a passive
Students are first introduced to ing positions. Standing postures treatment protocol.13 To work safely,
passive postures aimed at relieving require increased body awareness, Yoga students learn to use their intel-
pain. These postures are held from stability, and balance. Students are lectual judgment to discriminate
1–2 minutes using props for support educated from the beginning to be between healthy and unhealthy pain.
so that the student can learn to be aware of the differences between Students learn how to control
aware of muscular and mental ten- “healthy” discomfort due to length- their body position and posture by
sion and allow it to release. Accord- ening tight muscles and opening gradually introducing more chal-
ing to the amount of pain the student joints versus unhealthy pain caused lenging versions of the posture. The
is experiencing, instructions are by pulling muscles too aggressively sequence of postures progresses
repeated to help the student release or in an anatomically or structurally from supported poses on the floor in
incorrect gripping of the muscles and incorrect way. A quiet focused supine or prone positions and moves
bring awareness of correct move- attention heightens observation of toward seated, standing, or inverted
ments in the pose. Students experi- internal states, so that during per- positions, forward or backward
encing greater pain have less formance of postures the individual bends, and lateral rotational twists.
capacity to focus attention and is more sensitive to the effects of the Students progress gradually to pos-
greater musculoskeletal imbalances pose that are soothing or aggravat- tures that increase the range of flex-
to overcome. As a result, they require ing, which muscles and joints are ion and extension of the hip joint and
more repetition of instruction. The tight, and which side of the body is lengthen the hamstrings, hip adduc-
passive postures work to release tight performing correctly or incorrectly. tors, lateral rotators, and psoas mus-
superficial back muscles, increase This enables students to make cor- cle by releasing tense groins. They
circulation to the injured area, and rections in position from this feed- also progress to more challengingINTERNATIONAL JOURNAL OF YOGA THERAPY — No. 13 (2003) 59
postures with less support and modi- bones and creating internal traction muscles are frequently overpowered
fication that retrain the deeper and through intricate movements of the by stronger and larger peripheral
smaller back muscles. muscles and skin achieve this. As a muscles, which necessitates motor
The move toward more active result, the muscles are strengthened unit reeducation. In addition to stiff-
postures requires students to active- in their lengthened state. ness, hypermobility is a problem that
ly work to contract their muscles in The Yoga instructor targets needs to be addressed by teaching
an isometric contraction. All pos- many muscle groups with various students how to stabilize these areas.
tures require the coordinated move- categories of Yoga postures to foster Initially, this task is accomplished
ment of agonist and antagonist balanced mobility in the spine, to with external support with props,
muscles. Reciprocal inhibition lengthen and widen constricted or followed by independent action done
involves the release of the antagonist stiff muscles, and to strengthen those by students as they learn how to
muscle while the agonist muscle that are underutilized. Yoga postures align their bones and work their
contracts. Proprioceptive neuromus- lengthen, tone, and reeducate all muscles to create stability (e.g.,
cular facilitation involves isometric muscles that cause aggravation of standing on the feet and legs prop-
contraction of the muscles while the lower back to reinforce proper erly and raising the anterior spine to
they are being lengthened. Both motor patterns. These include all the create proper alignment of the pelvis
techniques are taught in Iyengar muscles that attach to or influence and femur heads in the acetabulum).
Yoga through the principle of intri- the pelvic girdle, including muscles
cacy. In contrast, isotonic contrac- of the abdomen, diaphragm, ham-
tion, which shortens the muscle strings, quadriceps, hip adductors
through repetitive motion, is avoided and lateral rotators, buttocks, and
in Iyengar Yoga. Load-bearing poses muscles of the lumbar and thoracic Themes Governing the
that counter the force of gravity, such areas of the back. The deep muscles Therapeutic Regime
as standing poses and inversions, of the back, including the erector
challenge students to develop spinae and transversospinalis mus- A number of themes govern the
strength and stamina. Aligning the cles, are specific targets. These small therapeutic regime. These include:
1) Lengthening the back extensor muscles (latissimus dorsi, erector spinae, multifidi, quadratus lumborum) evenly
on both sides of the torso decreases compression in the lower back. This involves creating an internal traction by
elevating the sternum and lengthening the lower back through moving the buttocks inferiorly away from the
waist. The sequence of poses includes: shavâsana II, supta-pavanamuktâsana, pavanamuktâsana on the bench,
ardha-uttânâsana over halâsana box and stool, adho-mukha-shvanâsana using upper wall ropes to traction and
align the hips against gravity, adho-mukha-vîrâsana , ûrdhva-dandâsana, supported garbha-pindâsana using
wall ropes, dandâsana, janu-shîrshâsana, and pashcimottânâsana.
Latissimus Dorsi Erector Spinae Multifidi Quadratus Lumborum Shavâsana II Supta-Pavanamuktâsana60 INTERNATIONAL JOURNAL OF YOGA THERAPY — No. 13 (2003) Pavanmuktâsana Ardha-Uttânâsana Ardha-Uttânâsana Adho-Mukha-Svanâsana Adho-Mukha-Vîrâsana Ûrdhva-Dandâsana Garbha-Pindâsana Dandâsana Janu-Shîrshâsana Pashcimottânâsana 2) Broadening the back of the pelvis is achieved by moving the front thighs back, internally rotating the femurs, and drawing the outer thighs up and in toward the hip socket, and by moving the buttocks down and the tailbone for- ward (posterior pelvic tilt). The movement created in the sacroiliac (SI) joints by the above maneuvers is referred to as gapping or distracting the SI joint and serves to relieve compression of the SI joints and the sciatic nerve. These lower extremity and pelvic movements also function to properly align the femural heads by contracting the hip adductors and relaxing the hip external rotators. Co-contraction of the quadriceps, hamstrings, tensor fas- cia latae, and gluteus maximus is performed to help stabilize the broad pelvis created by the above actions. Con- traction of these hip and thigh muscles is required for the correct performance of all symmetrical poses (tâdâsana, uttânâsana, adho-mukha-shvânâsana, prasârita-pâdottânâsana, dandâsana, pashcimottânâsana, shîrshâsana, and sarvângâsana) and in the grounded leg of many asymmetrical poses (supta-pâdângushthâsana I & II, utthita-hasta-pâdângushthâsana I & II, standing marîcyâsana, parivritta-trikonâsana, and parivritta- ardha-candrâsana). Sequencing to learn this action includes: prone shavâsana, supta-tâdâsana with legs tied together, ûrdhva-prasârita-pâdâsana, tâdâsana with brick between the thighs, ardha-uttânâsana over box, plat- form, and stool, adho-mukha-shvânâsana, prasârita-pâdottânâsana, utthita-padmâsana using the stool, parivritta-trikonâsana, parivritta-pârshvakonâsana, and parivritta-ardha-candrâsana. (See thematic category #5 for illustrations of the last three âsanas.) Abductors Adductors External hip rotators Prone Shavâsana Supta-Tâdâsana Ûrdhva-Prasârita-Pâdâsana Ardha-Uttânâsana Adho-Mukha-Shvânâsana Prasârita-Pâdottânâsana Utthita-Padmâsana
INTERNATIONAL JOURNAL OF YOGA THERAPY — No. 13 (2003) 61
3) SI joint compression is reduced by decreasing tension in the buttock region created by shortening and overwork
of the gluteal and hip lateral rotator musculature. This is achieved by manually turning the thighs inward (hip
internal rotation) to broaden the back of the buttock with assistance from the use of weighted props placed on the
buttock in the prone position. The added weight encourages lengthening of the buttock muscles. Sequencing
includes: prone shavâsana (an assistant pressing knuckles into SI joint and buttock area; weight on sacrum),
supta-pâdângushthâsana II prone with an assistant pressing the buttock inferiorly toward the feet, and watching
for signs of tension in the buttocks in tâdâsana, trikonâsana, vîrabhadrâsana II, pârshvakonâsana, ardha-can-
drâsana, vîrabhadrâsana III, and backbends.
Prone Shavâsana Prone Shavâsana Prone Supta-Pâdângushthâsana II
4) Proper alignment of the pelvis from right to left in the frontal plane (i.e., pelvic bones are of the same height on
the right and left sides of the body) and from front to back in the sagittal plane (avoiding anterior or posterior
pelvic tilt) is achieved to ensure an equal distribution of the weight-bearing load on the legs so that excessive
force is not placed on the spine in various positions. This occurs when the musculature of the lumbar spine,
pelvis, and hips is balanced. This balance is achieved in Yoga therapy by lengthening, toning, and strengthening
the muscles attached to these anatomical areas. They include the hamstrings, the hip adductors (inner thighs),
abductors (outer thighs,) and rotators, the abdominals, and the back muscles (especially the quadratus lumbo-
rum). Sequencing includes: supta-pâdângushthâsana II prone, supta-pâdângushthâsana I and II supine (wall
support followed by assisted traction followed by the use of a strap), and utthita-hasta-pâdângushthâsana I and
II. Once pelvic alignment has been accomplished in the above poses, the student is challenged to maintain align-
ment in the following standing poses: utthita-hasta-pâdâsana, utthita-trikonâsana, utthita-pârshvakonâsana,
ardha-candrâsana, pârshvottânâsana, prasârita-pâdottânâsana, vîrabhadrâsana III, and parighâsana.
Pelvis and Spine Iliopsoas and Pelvis Prone Supta-Pâdângushthâsana II Supta-Pâdângushthâsana I
Supta-Pâdângushthâsana I Utthita-Hasta-Pâdângushthâsana II62 INTERNATIONAL JOURNAL OF YOGA THERAPY — No. 13 (2003) Utthita-Hasta-Pâdâsana Utthita-Trikonâsana Utthita-Pârshvakonâsana Ardha-Candrâsana Pârshvottânâsana Prasârita-Pâdottânâsana Vîrabhadrâsana III Parighâsana 5) Rotating the spine is performed to access the deep layer of back muscles in order to realign the vertebrae, increase the intervertebral disc space, and decrease possible impingement of spinal nerve roots. This is achieved during spinal rotation by lengthening the spine through the elevation of the sternum and ribs and by stabilizing the pelvis so that it does not rotate with the spine. Active rotation of the spine activates the deep posterior back muscles, which include the rotators, the transversospinalis group, and the anterior abdominal oblique muscles. This trunk rotation maneuver coupled with active spinal extension performed by active contraction of the erector spinae muscles also will function to properly align the spine and lengthen the rectus abdominus. The latter mus- cle often becomes shortened in individuals with poorly aligned posture. Internal rotation of the hip relaxes and in some poses lengthens the hip lateral rotators, thus serving to maintain a broad pelvis. Sequencing includes: bharadvâjâsana on the chair, utthita-marîcyâsana, marîcyâsana III on simhâsana box, ardha-matsyendrâsana I, parivritta-trikonâsana, parivritta-pârshvakonâsana, parivritta-ardha-candrâsana, and jathara-parivar- tanâsana with knees bent. Rotator External Oblique Internal oblique Bharadvâjâsana Utthita-Marîcyâsana Marîcyâsana III Ardha-Matsyendrâsana I Parivritta-Trikonâsana Parivritta-Pârshvakonâsana Parivritta-Ardha-Candrâsana Jathara-Parivartanâsana
INTERNATIONAL JOURNAL OF YOGA THERAPY — No. 13 (2003) 63
6) Trunk rotation with hip flexion and side bending with hip abduction to the same side releases tension in both the back
and the side of the trunk. The former position is achieved by bending to one side at the hip and rotating the trunk
while maintaining spine extension. Movements in both poses involve the quadratus lumborum and the abdominal
oblique muscles. When bending to the right, both muscles are eccentrically contracted on the left to lower the trunk
to the right and eventually lengthened on the left once the pose is complete. With one arm over the head, the latis-
simus dorsi muscle is lengthened on the same side of the trunk as the raised arm. Extension of the spine is main-
tained during trunk rotation and side bending by the elevation of the sternum and erector spinae contraction. This
also lengthens the rectus abdominus. Sequence includes: pârshva-pavanamuktâsana and parighâsana.
Pârshva-Pavanamuktâsana Parighâsana
7) The compressive effects of gravity on the intervertebral disc space are reversed through performance of inverted
poses that use external support (props) and the weight of the upper body to create a traction effect on the spine.
In these poses, with the knees in terminal extension and the props supporting the legs and pelvis, the back exten-
sors lengthen resulting in a traction effect on the lumbar, thoracic, and cervical spine. Sequence includes: ûrd-
hva-dandâsana, rope shîrshâsana, and halâsana.
Ûrdhva-Dandâsana Rope Shîrshâsana Halâsana
8) The abdominal muscles (rectus abdominus, internal and external obliques) are toned to prevent anterior pelvic
tilt by elevating the sternum, contracting the abdominals to lift the legs off the floor, and rotating the spine.
Sequence includes: jathara-parivartanâsana with knees bent, ubhaya-pâdângushthâsana or V-shape supported
by a chair, plus standing poses and back extensions.
Jathara-Parivartanâsana Ubhaya-Pâdângushthâsana or V-shape64 INTERNATIONAL JOURNAL OF YOGA THERAPY — No. 13 (2003)
9) Mobility of the sacrum, shoulder girdle, and thoracic spine is increased and lumbar spine and pelvic stability is
established in order to distribute the concave curvature in back extensions evenly throughout the spine. All the
actions listed in thematic category #2 are required to maintain the stability of the pelvis during back extensions.
In addition, the iliopsoas major must lengthen in order for the sacrum to move forward to prevent compression
of the lumbar spine during back extensions. The normal kyphotic curve of the thoracic spine is decreased by per-
forming active thoracic spine extension (erector spinae) and by elevating the sternum and ribs. Proper alignment
of the shoulder girdle together with increasing its mobility is accomplished by activating scapular adductors and
depressors (trapezius) to draw shoulders back and down and by lengthening pectoralis major and minor. Active
extension of a normally aligned spine strengthens and increases endurance of the back muscles that can con-
tribute to the reduction of interveterbral disc space compression. Sequence includes the following supported
poses: vîrabhadrâsana I at the trestler, ûrdhva-mukha-shvânâsana on the stool or using upper wall ropes,
ushtrâsana over bolsters on the halâsana box, ûrdhva-dhanurâsana over trestler or using the backbender,
sâlamba-sarvângâsana at the trestler, and shalabhâsana over bolsters.
Iliopsoas and Pelvis Hip Flexors Chest Muscles Upper Back Muscles
Vîrabhadrâsana I Ûrdhva-Mukha-Shvânâsana Ushtrâsana
Ûrdhva-Dhanurâsana Sâlamba-Sarvângâsana Shalabhâsana
Scientific Studies of Yoga patients.14 In the 29 patients that involving back extension. In the first
Therapy for LBP were followed, 22 reported complete phase, patients practiced nirâlam-
pain relief, 5 required modification bâsana and bhujângâsana daily for
The scientific study of Yoga is in of the therapy because of severe 45 minutes with 10 minute intervals
its infancy. To date, there has only pain, and 7 obtained no pain relief of rest in makarâsana. In the second
been one study in a peer-reviewed and discontinued treatment. The phase, patients practiced pâr-
journal on the effect of Yoga on LBP. Yoga intervention consisted of three vatâsana and ushtrâsana. In the third
Vidyasagar et al. examined the effect phases, each three weeks long, and phase, patients practiced shalab-
of Yoga on non-specific LBP in 33 primarily used classical postures hâsana and dhanurâsana. AlthoughINTERNATIONAL JOURNAL OF YOGA THERAPY — No. 13 (2003) 65
the majority of patients reported pain are done using props for external compensation, those who had a com-
relief, this study was not adequately support. They are taught after the promised cardiopulmonary system,
controlled, had a small sample size, student has learned the basic actions were pregnant, had a body mass
and did not describe how pain status in standing and seated poses, inver- index ≥ 35, and/or had major depres-
was assessed. sions, forward bends, and twists. sion or a substance abuse issue. Only
There are very few studies of According to B. K. S. Iyengar, the individuals who were willing to
Iyengar Yoga. However, those that above back extensions used by commit to attending 14 of the 16
have been done have been well Vidyasagar19 are harmful to persons weeks of classes (if randomized to
designed and have overcome some with LBP who are not trained in the the Yoga therapy group) and who
of the pitfalls of other Yoga studies. intricate movements of the pose. agreed to forgo other forms of CAM
Garfinkle et al. conducted two well- Beginners are unable to obtain cor- during the study were included. Both
controlled studies of the therapeutic rect alignment of the spinal vertebrae groups were allowed to continue
application of Iyengar Yoga on and musculature in the back exten- medical care for LBP.
carpel tunnel syndrome and osteo- sions without the guidance of an The following results were
arthritis of the hands.15,16 Subjects experienced teacher in the Iyengar obtained from a study by Williams et
randomized to the Yoga regime in method and without external sup- al.20 Of 210 candidates invited to par-
both studies demonstrated signifi- port. B. K. S. Iyengar has observed ticipate in the study, 70 (33%) met
cant improvements compared to that although there is a concave the inclusion criteria and 60 (29%)
control groups. Patients with carpal appearance of the back bend, in the agreed to enroll. One hundred-forty
tunnel syndrome reported significant untrained student the spinal verte- candidates were excluded before
improvement in grip strength, phalen brae undergo an incorrect convex enrollment for the following rea-
sign, and pain reduction whereas movement, along with the muscula- sons: logistical conflicts (72.8%),
patients with osteoarthritis reported ture improperly contracting toward contraindicated medical conditions
significant improvements in pain the vertebrae. (13.6%), unwillingness to forgo
during activity, tenderness, and fin- The current study uses a ran- other forms of CAM (13.6%). In
ger range of motion. DiCarlo et al. domized controlled trial with sub- addition, ten (14.3%) of the 70 eligi-
compared the cardiovascular, meta- jects with nonspecific chronic LBP ble candidates dropped out before
bolic, and perceptual responses of 10 to compare Iyengar Yoga therapy to enrollment. Three of the remaining
beginning subjects performing a vig- an educational control group receiv- 60 eligible subjects were excluded
orous routine of Iyengar-style stand- ing weekly newsletters on topics following the start of the study due
ing poses to a 32-minute treadmill related to recovery of LBP. Both pro- to pregnancy, degenerative disc dis-
walk.17 They found that heart rate, grams were 16 weeks long and ease, and a herniated disc. Out of 57
blood pressure, and perceived level included two education sessions on subjects enrolled at the beginning of
of exertion were higher during Yoga chronic LBP by a physical therapist the study 42 completed the study,
than treadmill walking, while oxy- and an occupational therapist prior to giving an overall rate of completion
gen consumption was higher during the start of the programs. Study of 74%. Of the 20 subjects complet-
walking than Yoga. This study used a inclusion criteria were as follows: ing the Yoga intervention, an atten-
very demanding protocol for begin- history of nonspecific LBP with dance rate of 91.9% was achieved
ning students, and poses would not symptoms for ≥ three months, >18 for the 16-week protocol.
typically be held for 40 seconds each years of age, English speaking, and Of the final 42 participants who
side with beginners. ambulatory. Individuals were ex- completed the entire study, the over-
This study examines the thera- cluded if their LBP was due to nerve all mean age was 48.3 ± 1.5 years
peutic application of Iyengar Yoga in root compression, disc prolapse, with the youngest participant 23
people with chronic LBP. The inter- spinal stenosis, tumor, spinal infec- years old and the oldest 67. Ninety-
vention is quite different from that tion, alkylosing spondylitis, spondy- one percent of the participants in the
used by Vidyasagar et al.18 No back lolisthesis, kyphosis, structural study were Caucasian (N=40) with
extensions were taught during the scoliosis, symptomatic osteoarthritis ethnic diversity represented by two
16-week Iyengar Yoga therapy pro- or degenerating disc disease, or a African-Americans (4.5%), one
gram described below. Furthermore, widespread neurological disorder. Asian (2.2%), and one Native Amer-
when back extensions are incorpo- Also precluded were pre-surgical ican (2.2%). Sixty-eight percent of
rated in Iyengar yoga therapy, they candidates involved in litigation or the sample was female and 32% was66 INTERNATIONAL JOURNAL OF YOGA THERAPY — No. 13 (2003)
male. Subjects had LBP for an aver- the primary outcome and in a num- Surprisingly, beliefs, attitudes, and
age of 11.2 ± 1.54 years, 48% used ber of secondary outcomes com- behaviors about pain, with the
pain medication, and 30% used some pared to the control group after exception of perceived control over
form of CAM for LBP. A one-way completion of the program. These pain, were not significantly different
analysis of variance (unpaired t-test) include a 77% reduction in func- from the control after the interven-
revealed no significant differences in tional disability (p=.0053), 64% tion. This may be due to the weekly
demographics and medical history decrease in present pain (p=.0180), education of the control group about
between the Yoga group and the con- 10% increase in standing hip flexion a variety of topics related to chronic
trol group (p> .05) suggesting that (p=.015), and 25% increase in per- LBP including psychological and
randomization was effective. Com- ceived control over pain (p=.005). In behavioral factors. The pilot study
parison of baseline scores of out- addition, the Yoga group has a trend gave the Yoga instructor and assis-
come variables in the two groups toward greater pain tolerance to tants an opportunity to test the 16-
indicated that no significant differ- pressure compared to controls at a week Yoga therapy curriculum. It
ences existed in the majority of vari- number of locations in the low back was quickly realized that the time
ables with the exception of 4 and pelvis. These include standard allotted was too short to deliver the
subscale scores. The Yoga group trigger point locations for right glu- complete protocol for LBP designed
reported significantly higher func- teus medius (p=.053), right ilio- by B. K. S. Iyengar as described
tional ability on the self-efficacy costalis (p=.085), and left iliocostalis above and for subjects to become
questionnaire (p=.005), lower cata- (p=.08). Between-group differences proficient in the actions and align-
strophizing on the coping strategies were only obtained in pain tolerance ment required for optimal therapeu-
questionnaire (p=.007), and less per- on the left quadratus lumborum mus- tic benefit. The subjects also
ceived disability (p=.002) and harm cle (p=.016).The Yoga group had a expressed that they were just begin-
(p=.02) on the survey of pain atti- 16% increase in pain tolerance at this ning to become proficient in the
tudes questionnaire than the control site after the 16-week Yoga therapy poses by the end of the program and
group. program. Pain medication usage was would have liked to continue. Thus
One-way analysis of demo- also significantly reduced in the future studies will involve a longer
graphic factors, medical history, Yoga group compared to the control program and the opportunity for stu-
baseline pain intensity, and disability group at both post and three-month dents to practice the poses outside of
comparing subjects who completed follow-up assessments (p < .01). In class time at the Yoga studio under
the study (N=42) and subjects who the Yoga group, 88% of the subjects supervision. We have submitted a
either dropped out or were lost to fol- taking pain medication for LBP at proposal to the National Center for
low-up (N=15) revealed no signifi- baseline either stopped or used less Complementary and Alternative
cant between-group differences in compared to 35% in the control Medicine at the National Institutes of
demographics or baseline disability group immediately after completion Health to continue this research.
or pain intensity. However, non-com- of the program.
pleters had LBP for a longer period These preliminary data are I would like to thank all the people
of time (16.4 ± 2.5 yrs) compared to important for a number of reasons. who have helped me to understand
completers (10.21 ± 1.51 yrs). They determined that the majority of the therapeutic application of Iyen-
In the Yoga group, there was self-referred persons with nonspe- gar Yoga for chronic low back pain.
84% attendance of classes (including cific chronic LBP would comply First and foremost, I would like to
dropouts; 92% excluding dropouts) with Iyengar Yoga therapy. Further- acknowledge the genius of B. K. S.
and a 74% completion rate at the more, a significant number of sub- Iyengar and how his deep under-
post and three-month follow-up. In jects reported improvement in standing of Yoga guided him in the
the control group, 80% of subjects pain-related outcomes from a 16- development of this program. I am
completed the post assessment and week program. From the variety of deeply grateful for his suggestions
73% completed the three-month fol- outcomes tested, present pain inten- for this article. I would also like to
low-up assessment. sity, functional disability, perceived thank Geeta Iyengar for her guid-
In the analysis of covariance that control over pain, and hip flexion ance in my own recovery from
controlled for baseline score, sub- were significantly improved and chronic low back pain at the Rama-
jects in the Yoga therapy group pain medication usage was de- mani Iyengar Memorial Yoga Insti-
reported significant improvements in creased by Iyenger Yoga therapy. tute in Pune, India. Special thanks toINTERNATIONAL JOURNAL OF YOGA THERAPY — No. 13 (2003) 67
the senior Iyengar teachers (Mar- 3. NCCAM. Mind-body interventions. 20 non-specific low back pain. Clinical Pro-
lene Mawhinney, Lois Steinberg, and Sep 2003. URL: http://nccam.nih.gov/ ceedings of NIMS, 1989, 4:160–164.
health/whatiscam/. 15. Garfinkel, Schumacher, et al., op. cit.
Manouso Manous) and Iyengar-
4. Iyengar, B. K. S. Light on Yoga. New 16. Garfinkel, Singhal, et al., op. cit.
trained clinicians who continue to
York: Schocken Books, 1976.
teach me how to stay pain free 17. DiCarlo, L. J., P. B. Sparling, B. T.
5. Iyengar, B. K. S. Light on Pranayama: Hinson, T. K. Snow, and L. B. Rosskopf.
through proper performance of The Yogic Art of Breathing. New York: Cardiovascular, metabolic, and perceptual
âsana. I would also like to acknowl- Crossroad Publishing, 1989. responses to hatha yoga standing poses.
edge the assistance of David 6. Schatz, M. P. Back Care Basics. Berke- Medicine, Exercise, Nutrition and Health,
Goodrich, Marybeth Korf, N. Noer- ley, Calif.: Rodmell Press, 1992. 1995, 4:107–112.
achmanto, and Kirsten Dennison in 7. Raman, K. A Matter of Health: Integra- 18. Vidyasagar et al., op. cit.
the preparation of this manuscript. tion of Yoga and Western Medicine for 19. Ibid.
Special thanks to graphic artist Prevention and Cure. Chennai (Madras),
India: Eastwest Books, 1998. 20. Williams, K., J. Petronis, D. Smith, L.
Francoise Stauber for her drawings Steinberg, E. Doyle, M. Kolar, et al. Effect
of the musculoskeletal system per- 8. Garfinkel, M. S., H. R. Schumacher, Jr., of Iyengar Yoga therapy on chronic low
A, Husain, M. Levy, and R. A. Reshetar. back pain. Submitted to Pain Journal 2003.
taining to the back. Evaluation of a yoga based regimen for
treatment of osteoarthritis of the hands. © Kimberly Williams, Lois Stein-
With the exception of the “Pelvis and Journal of Rheumatology, 1994, 21: berg, and John J. Petronis 2003
Spine” and “Iliopsoas and Pelvis” 2341–2343.
illustrations, all musculoskeletal 9. Garfinkel, M. S., A. Singhal, W. A.
images courtesy of Primal Pictures. Katz, D. A. Allan, R. Reshetar, and H. R.
Schumacher, Jr. Yoga-based intervention
For more information on their inter- for carpal tunnel syndrome: A randomized
active 3D anatomy software please trial. Journal of the American Medical
go to www.primalpictures.com. Association, 1998, 280:1601–1603.
10. Schatz, op. cit. Kimberly Williams
Endnotes 11. Iyengar, P. S. Yoga and the new mil- Tel.: 304-293-7559
lennium. Yoga Rahasya, 1998. Email: kwilliams@hsc.wvu.edu
1. Druss, B. G., S. C. Marcus, M. Olfson,
and H. A. Pincus. The most expensive 12. Steinberg, L. Iyengar Yoga Therapeu-
medical conditions in America. Health tics: The Lower Back. Unpublished work, Lois Steinberg
Affairs, 2002, 21:105–111. 2002.
Tel.: 217-344-YOGA
2. Eisenberg, D. M., R. C. Kessler, C. 13. Lively, M. W. Sports medicine ap- Email: lsteinbe@uiuc.edu
Foster, F. E. Norlock, D. R. Calkins, and proach to low back pain. Southern Med-
T. L. Delbanco. Unconventional medicine ical Journal, 2002, 95:642–646.
in the United States: Prevalence, costs, 14. Vidyasagar, J. V. S., B. N. Prasad, M.
John Petronis
and patterns of use. The New England V. Reddy, P. S. Raju, M. Jayshankar, and Tel.: 304-293-1561
Journal of Medicine, 1993, 328:246–252. K. Sampath. Effects of yoga practices in Email: jpetronis@hsc.wvu.eduYou can also read
