Iyengar Yoga for Herniated Disc

INTERNATIONAL JOURNAL OF YOGA THERAPY — No. 13 (2003) 55

AbstractLow back pain is a significant public health problem

that has reached epidemic proportions. It places a sub-stantial burden on the workforce and the health care sys-tem.1 It has proven very difficult to treat, and it is one ofthe most commonly reported reasons for the use of com-plementary and alternative medicine.2 Many differentmethods of Yoga exist and each has its own technique forpreventing and treating disease. This article describesthe rationale and method for the therapeutic applicationof Iyengar Yoga for chronic low back pain. Preliminaryresults are also presented from a pilot study evaluatingthe efficacy of a 16-week program of Iyengar Yoga ther-apy in persons with non-specific chronic low back pain.

Introduction

Yoga is a 5,000-year-old tradition whose classicalaim is liberation from suffering in this life. Ancient textsmake it clear that mental and physical illness or lack ofhealth are impediments to this goal. Yoga was used inantiquity to overcome these impediments in preparationfor attaining the goal of self-realization and liberationfrom suffering. Although the ancient seers recognizedthe health and healing effects of Yoga, they were not theprimary goal of practice as is the case in America today.Yoga is now regarded in the West as a holistic approachto health and recently has been classified by the NationalInstitutes of Health as a form of Complementary and

Alternative Medicine (CAM).3 In India, however, Yogais not an alternative healing system but a part of main-stream medicine. In either case, this therapeutic applica-tion of Yoga requires the classical postures to be adaptedto address the specific problems associated with eachmedical condition.

Many different methods of Yoga exist and each hasits own technique for preventing and treating disease. Themost common methods of Yoga therapy in the US are theIyengar method, Viniyoga, Integrative Yoga Therapy, andPhoenix Rising Yoga Therapy. The Iyengar method isbased on the teachings of the Yoga master B. K. S. Iyen-gar, author of the classics Light on Yoga4 and Light onPranayama.5 Iyengar’s teachings are deeply grounded inthe ancient Yoga tradition, and his intense personal prac-tice and more than 60 years of teaching have producedsignificant innovations. Among the most noteworthy are:1) an emphasis on standing poses to develop strength, sta-bility, stamina, concentration, and body alignment, 2) theuse of props to facilitate learning and to adjust poses forthose who are inflexible, and 3) instruction on how to useYoga to ease various ailments and stress.

His system is based on the eight constituents ofPatanjali’s Astanga-Yoga that lead to self-realization andliberation. They include yama, niyama, âsana, prânâ-yâma, pratyâhâra, dhârâna, dhyâna,and samâdhi. Mostschools of Yoga practice each limb separately usingâsanaas preparation for meditation. Iyengar’s uniquecontribution has been the realization that all limbs may be

Therapeutic Application of Iyengar Yoga forHealing Chronic Low Back PainKimberly Williams, Ph.D., Lois Steinberg, Ph.D., and John Petronis, M.S.

56 INTERNATIONAL JOURNAL OF YOGA THERAPY — No. 13 (2003)

practiced and integrated into âsanaand prânâyâma.

The therapeutic application ofIyengar Yoga has been used in med-ical settings6,7 and in Yoga centers byteachers having Junior IntermediateIII or higher certification.

This paper will describe the ther-apeutic application of Iyengar Yogafor treatment of chronic low backpain, the rationale behind themethod, and preliminary findingsfrom a pilot study evaluating theefficacy of a 16-week program withambulatory adults with chronic lowback pain.

The Goal of Yoga Therapyfor Low Back Pain

The primary goal of Yoga ther-apy for low back pain (LBP) is therelief of pain and functional limita-tion caused by a chronic lower backdisorder. This is achieved by mini-mizing, healing, and ultimately cor-recting underlying physical mal-functions through a series of anatom-ically correct postures. Unlike mostconventional medical treatments thatfocus on treating LBP symptomsthrough medications and surgicalprocedures, Yoga therapy works tocorrect underlying internal malfunc-tions that contribute to mechanicalcauses of non-specific LBP. It isthrough the process of helping peo-ple with LBP to rest the area of painand then educating them in properalignment of bones, muscles, andconnective tissue and movementsthat the healing occurs and changesthe underlying root cause of the dis-comfort. The practice of Yoga isdesigned to educate students in theuse of a daily regimen of self-carethat acts to manage and ultimatelyprevent the recurrence of chronicLBP through healthy postural andmovement patterns.

Reasons for ImplementingTherapeutic Yoga for LowBack Pain

Although the regular practice ofIyengar Yoga is viewed to be healingand health retaining,8,9 there are sev-eral reasons for implementing a ther-apeutic version of Yoga for someonewith LBP. Classical postures requireeffort and skill to be health enhanc-

ing and therapeutic, whereas an indi-vidual in pain requires the injuredarea to rest prior to introducing cor-rective action. It also takes time todevelop the awareness and neuro-muscular coordination to perform theposes in a way that corrects imbal-ances contributing to LBP. In addi-tion, Yoga therapy relies much moreon external support through the use ofprops. This external support enablesthe student to rest the injured areaand achieve correct postural align-ment and movement in the postures.

Specific body positioning foreach Yoga posture opens and createsspace longitudinally, horizontally,and circumferentially without aggra-vating injured areas. Iyengar Yoga isnoteworthy because this particularmethod incorporates props such asropes, benches, bolsters, blankets,weights, straps, blocks, and otherdevices to provide support duringperformance of the postures. Propsare useful for facilitating rest andrelaxation, avoiding unnecessarystrain, revealing latent musclestrains, inflammation, or restrictionsdue to stiffness or injury, and forhelping the student achieve correct

body position and movement in thepostures. These props also helpimmobilize joints so that specificareas are targeted. They also providecontrolled traction, which assistsactive or passive forms of movementdepending on the pose and thecapacity of the student. It is the ulti-mate goal of Yoga therapy to enablea student to attain a healthy back freefrom LBP. The teacher assists thestudent to transition from supportedposes to the execution of classicalposes without support. Practice ofthe classical postures furthers thestudent’s awareness of latent imbal-ances and requires mastery of cor-rective movements.

The Evaluation Procedure

Iyengar Yoga therapy beginswith an evaluation of an individual’sknown medical history for possiblecauses of pain followed by a diag-nostic examination of the student.The instructor performs this initialexamination as the student performstâdâsana(mountain pose), a basicstanding pose that permits theinstructor to look for signs of dys-function and imbalance in specificregions of the body such as the feet,legs, knees, hips, torso, chest, shoul-ders, neck, head, and carriage, andhow these dysfunctions affect pos-ture, levelness of the pelvic girdle,alignment of the spinal vertebrae,and gait. Attention is paid to thealignment of bones and pelvis, mus-cle tone, and the tightness, hardness,or color of the skin for signs of mus-cle imbalance and poor circulation.

The Yoga instructor continues togain insight into the biomechanicalcauses of LBP from observing per-formance of the postures. Areas oftightness and hyperflexibility thatcreate imbalances in the muscu-loskeletal system are exposed. Theinstructor is particularly interested in

Iyengar’s system is basedon the eight constituentsof Patanjali’s Astanga-Yoga that lead to self-realization and liberation.


evaluating a student’s limitation ofmovement in several directionsaccording to the person’s height,weight, flexibility, and lifestyle(sedentary vs. active). In most stu-dents, dysfunction occurs due toeither stiffness in the lower backmuscles or tightness in the hips,quadriceps, hamstrings, groin, orthoracic spine. Such stiffness ortightness leads to difficulties inspinal and pelvic rotation, lateralbending, and forward or backwardextension. Unlike many traditionalphysical therapy rehabilitative exer-cises that focus primarily on defi-ciencies in flexion or extension,therapeutic Iyengar Yoga works toenhance alignment, flexibility, mo-bility, and stability in all muscles andjoints that affect spinal alignmentand posture.10

Structuring the Therapy

The Iyengar principles ofsequencing, timing, and intricacy ofposes provide a framework for thera-peutic instructors to structure theprogression and content of therapy.11

Sequencingrefers to the deliberateprogression of postures selected by aninstructor to specifically target agroup of muscles, with variations ofpostures that gradually release muscletension, open up joint spaces, increasecirculation, and decrease inflamma-tion. It also refers to the order inwhich students are asked in moreactive poses to engage various musclegroups to achieve the correct align-ment and movement in the postures.

Timing refers to the length oftime each pose or âsana is held,depending on the capacity of the stu-dent, to optimize the release of ten-sion and “opening” of joints whileminimizing pain. Iyengar philoso-phy posits that passive weightedposes, such as prone shavâsana(corpse pose) and tractioned poses,

such as prone supta-pâdân-gushthâsana(supine foot–big toepose), should ideally be done for upto five minutes to reduce inflamma-tion, achieve optimal length of thejoint, muscle, and connective tissue,and to optimize retraining of mus-cles. When mobility is the goal,

more active stretching is involvedand poses are held for short timeperiods (15–20 seconds) and re-peated up to 8 times so that sorenessdoes not develop from strain or over-stretching in beginners. Once mobil-ity is achieved, the student isinstructed to stay longer in the pose(1–2 minutes) with less repetitionaccording to their capacity to regainproper anatomical alignment, flexi-bility, and strength.

Finally, all postures must be per-formed in a consciously aware man-ner that is fully appreciative of theintricacy of each adjustment,appraising, quantifying, and qualify-ing movements to obtain properalignment in the pose. B. K. S. Iyen-gar noted that many beginning Yogastudents have difficulty monitoringsimultaneous contractions that mustnecessarily occur in multiple mus-cles groups to assure that a pose isperformed to achieve the optimaltherapeutic effect. For instance, inthe fundamental position tâdâsana(mountain pose) students are askedto move their frontal thighs back-ward and their outer thighs inward,simultaneously. Cognitive aware-ness and control are required toinsure that proper physical position-ing occurs when many simultaneousand often opposing actions are to beperformed in a posture. These move-ments are “intricate” and highlight

the mind-body nature of Yoga thatemphasizes awareness, concentra-tion, and bidirectional communica-tion between the mental, nervous,skeletal, and muscular systems.

Yoga is not a passive activitythat simply occurs by itself; itinstead requires an active mind and

body integration to assure theanatomically correct pose occursthat stimulates all muscles and tis-sues to achieve proper alignment,strengthening, flexibility, stability,and physiological function of thesurrounding tissues and organs. Theintricacy that occurs allows practi-tioners to stay in the pose for longerperiods of time, at first with effort.As they practice and progress, theycan remain in the pose with a light-ness and ease. Sustaining the posturein a dynamic state permits positivephysical and psychological changesto occur, and intricacy is thus centralto the healing of musculoskeletalimbalances. Maintaining a numberof opposing muscular movementscreates internal traction that length-ens constricted muscles and connec-tive tissue and increases disc andjoint space.

The Setting

Iyengar Yoga instructors workeither individually or in a classroomsetting with each student to create aseries of postures to perform at eachsession that are most beneficial foreach individual and that are prac-ticed in a manner that minimizespotential harm to the student. A typi-cal therapy session will start withseveral passive postures that arevariations of a selected movement

All postures must be performed in a consciouslyaware manner that is fully appreciative of the intri-cacy of each movement.


(e.g., groin extension or hip opener)and move toward postures that thestudent must work actively toachieve involving countering theforce of gravity. The end of a sessionis concluded with passive postures toquiet the mind and relax the body. Asthe student progresses, the passivepostures at the beginning of the ses-sion are eliminated.

The Method

The Iyengar method of Yogatherapy for LBP targets a number ofareas in the body by using a series ofpostures from all categories of posesto address imbalances in thoseareas.12 Postures are structured towork peripherally from the injurysite. The initial poses address grossor superficial layers of the imbalanceor misalignment. These are followedby more challenging poses thataffect deeper or more subtle mis-alignments. Each pose in a sequenceadds to students’ understanding ofthe imbalance and teaches studentshow to correctly align and work theirmusculoskeletal system.

Students are first introduced topassive postures aimed at relievingpain. These postures are held from1–2 minutesusing props for supportso that the student can learn to beaware of muscular and mental ten-sion and allow it to release. Accord-ing to the amount of pain the studentis experiencing, instructions arerepeated to help the student releaseincorrect gripping of the muscles andbring awareness of correct move-ments in the pose. Students experi-encing greater pain have lesscapacity to focus attention andgreater musculoskeletal imbalancesto overcome. As a result, they requiremore repetition of instruction. Thepassive postures work to release tightsuperficial back muscles, increasecirculation to the injured area, and

decrease inflammation. It is impor-tant for the muscles to release andreturn to their normal position rela-tive to tissues, bones, and organsprior to a more active phase of cor-recting underlying imbalances.External props such as plate weightsand sandbags in conjunction withgravity are used to encourage tightmuscles and tissues to relax.

Besides providing rest to theinjured area, the passive posturesimpose a gentle lengthening of tightor inflexible areas and begin realign-ing imbalanced areas and increase

flexibility in joints, connective tis-sues, and muscles.

Passive postures also enable thelearning of different actions in posesby students prior to their attempt topractice the more demanding stand-ing positions. Standing posturesrequire increased body awareness,stability, and balance. Students areeducated from the beginning to beaware of the differences between“healthy” discomfort due to length-ening tight muscles and openingjoints versus unhealthy pain causedby pulling muscles too aggressivelyor in an anatomically or structurallyincorrect way. A quiet focused attention heightens observation ofinternal states, so that during per-formance of postures the individualis more sensitive to the effects of thepose that are soothing or aggravat-ing, which muscles and joints aretight, and which side of the body isperforming correctly or incorrectly.This enables students to make cor-rections in position from this feed-

back with the help of the teacher. These passive postures are fol-

lowed by supported postures involv-ing more active stretching. This isachieved by providing traction inthese postures by the gentle physicaladjustment of an instructor, and bythe use of external props such as wallropes, benches, trestle, and gravity.Gravity is a powerful force that isused to release muscular tension(sandbags, weights as noted above)and to create extension in the spine.This is initially provided throughexternal support but is ultimatelycreated by forces in the body of theskilled student, which counter theforce of gravity.

As back pain mitigates and flex-ibility, strength, and postural align-ment improve, instructors guidestudents through postures that chal-lenge the back. The more active cor-rective phase of Yoga is consistentwith current sports medicineapproaches to LBP therapy in whichpatients must actively treat the lowback pain through physical work thatinitially causes discomfort butreduces pain relative to a passivetreatment protocol.13 To work safely,Yoga students learn to use their intel-lectual judgment to discriminatebetween healthy and unhealthy pain.

Students learn how to controltheir body position and posture bygradually introducing more chal-lenging versions of the posture. Thesequence of postures progressesfrom supported poses on the floor insupine or prone positions and movestoward seated, standing, or invertedpositions, forward or backwardbends, and lateral rotational twists.Students progress gradually to pos-tures that increase the range of flex-ion and extension of the hip joint andlengthen the hamstrings, hip adduc-tors, lateral rotators, and psoas mus-cle by releasing tense groins. Theyalso progress to more challenging

The more active correc-tive phase of Yoga isconsistent with currentsports medicine ap-proaches to LBP therapy.


postures with less support and modi-fication that retrain the deeper andsmaller back muscles.

The move toward more activepostures requires students to active-ly work to contract their muscles inan isometric contraction. All pos-tures require the coordinated move-ment of agonist and antagonistmuscles. Reciprocal inhibitioninvolves the release of the antagonistmuscle while the agonist musclecontracts. Proprioceptive neuromus-cular facilitation involves isometriccontraction of the muscles whilethey are being lengthened. Bothtechniques are taught in IyengarYoga through the principle of intri-cacy. In contrast, isotonic contrac-tion, which shortens the musclethrough repetitive motion, is avoidedin Iyengar Yoga. Load-bearing posesthat counter the force of gravity, suchas standing poses and inversions,challenge students to developstrength and stamina. Aligning the

bones and creating internal tractionthrough intricate movements of themuscles and skin achieve this. As aresult, the muscles are strengthenedin their lengthened state.

The Yoga instructor targetsmany muscle groups with variouscategories of Yoga postures to fosterbalanced mobility in the spine, tolengthen and widen constricted orstiff muscles, and to strengthen thosethat are underutilized. Yoga postureslengthen, tone, and reeducate allmuscles that cause aggravation ofthe lower back to reinforce propermotor patterns. These include all themuscles that attach to or influencethe pelvic girdle, including musclesof the abdomen, diaphragm, ham-strings, quadriceps, hip adductorsand lateral rotators, buttocks, andmuscles of the lumbar and thoracicareas of the back. The deep musclesof the back, including the erectorspinae and transversospinalis mus-cles, are specific targets. These small

muscles are frequently overpoweredby stronger and larger peripheralmuscles, which necessitates motorunit reeducation. In addition to stiff-ness, hypermobility is a problem thatneeds to be addressed by teachingstudents how to stabilize these areas.Initially, this task is accomplishedwith external support with props,followed by independent action doneby students as they learn how toalign their bones and work theirmuscles to create stability (e.g.,standing on the feet and legs prop-erly and raising the anterior spine tocreate proper alignment of the pelvisand femur heads in the acetabulum).

Themes Governing theTherapeutic Regime

A number of themes govern thetherapeutic regime. These include:

1) Lengthening the back extensor muscles (latissimus dorsi, erector spinae, multifidi, quadratus lumborum) evenlyon both sides of the torso decreases compression in the lower back. This involves creating an internal traction byelevating the sternum and lengthening the lower back through moving the buttocks inferiorly away from thewaist. The sequence of poses includes: shavâsanaII, supta-pavanamuktâsana, pavanamuktâsanaon the bench,ardha-uttânâsanaover halâsanabox and stool, adho-mukha-shvanâsanausing upper wall ropes to traction andalign the hips against gravity, adho-mukha-vîrâsana , ûrdhva-dandâsana, supported garbha-pindâsanausingwall ropes, dandâsana, janu-shîrshâsana, and pashcimottânâsana.

Latissimus Dorsi Erector Spinae Multifidi Quadratus LumborumShavâsana II Supta-Pavanamuktâsana


2) Broadening the back of the pelvis is achieved by moving the front thighs back, internally rotating the femurs, anddrawing 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 referredto 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 contractingthe 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-pâdângushthâsanaI & II, utthita-hasta-pâdângushthâsanaI & II, standing marîcyâsana, parivritta-trikonâsana, and parivritta-ardha-candrâsana). Sequencing to learn this action includes: prone shavâsana, supta-tâdâsanawith legs tiedtogether, ûrdhva-prasârita-pâdâsana, tâdâsanawith brick between the thighs, ardha-uttânâsanaover box, plat-form, and stool, adho-mukha-shvânâsana, prasârita-pâdottânâsana, utthita-padmâsanausing 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

Pavanmuktâsana Ardha-Uttânâsana Ardha-Uttânâsana Adho-Mukha-SvanâsanaAdho-Mukha-Vîrâsana

Ûrdhva-Dandâsana Garbha-Pindâsana Dandâsana Janu-Shîrshâsana Pashcimottânâsana


Prone Shavâsana Prone Shavâsana Prone Supta-Pâdângushthâsana II

3) SI joint compression is reduced by decreasing tension in the buttock region created by shortening and overworkof the gluteal and hip lateral rotator musculature. This is achieved by manually turning the thighs inward (hipinternal rotation) to broaden the back of the buttock with assistance from the use of weighted props placed on thebuttock in the prone position. The added weight encourages lengthening of the buttock muscles. Sequencingincludes: prone shavâsana(an assistant pressing knuckles into SI joint and buttock area; weight on sacrum),supta-pâdângushthâsanaII prone with an assistant pressing the buttock inferiorly toward the feet, and watchingfor signs of tension in the buttocks in tâdâsana, trikonâsana, vîrabhadrâsana II , pârshvakonâsana, ardha-can-drâsana, vîrabhadrâsanaIII, and backbends.

4) Proper alignment of the pelvis from right to left in the frontal plane (i.e., pelvic bones are of the same height onthe right and left sides of the body) and from front to back in the sagittal plane (avoiding anterior or posteriorpelvic tilt) is achieved to ensure an equal distribution of the weight-bearing load on the legs so that excessiveforce 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 strengtheningthe 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-pâdângushthâsanaII prone, supta-pâdângushthâsanaI and II supine (wallsupport followed by assisted traction followed by the use of a strap), and utthita-hasta-pâdângushthâsanaI andII. 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, vîrabhadrâsanaIII, and parighâsana.

Pelvis and Spine Iliopsoas and Pelvis Prone Supta-Pâdângushthâsana II Supta-Pâdângushthâsana I

Supta-Pâdângushthâsana I Utthita-Hasta-Pâdângushthâsana II


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 achievedduring spinal rotation by lengthening the spine through the elevation of the sternum and ribs and by stabilizingthe pelvis so that it does not rotate with the spine. Active rotation of the spine activates the deep posterior backmuscles, 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 erectorspinae 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 insome poses lengthens the hip lateral rotators, thus serving to maintain a broad pelvis. Sequencing includes:bharadvâjâsanaon the chair, utthita-marîcyâsana, marîcyâsanaIII on simhâsanabox, ardha-matsyendrâsanaI,parivritta-trikonâsana, parivritta-pârshvakonâsana, parivritta-ardha-candrâsana, and jathara-parivar-tanâsanawith knees bent.

Rotator External Oblique Internal oblique Bharadvâjâsana Utthita-Marîcyâsana Marîcyâsana III

Ardha-Matsyendrâsana IParivritta-Trikonâsana Parivritta-Ardha-CandrâsanaParivritta-Pârshvakonâsana Jathara-Parivartanâsana

Utthita-Hasta-Pâdâsana Utthita-Trikonâsana Utthita-Pârshvakonâsana Ardha-Candrâsana

Pârshvottânâsana Prasârita-Pâdottânâsana Vîrabhadrâsana III Parighâsana


Pârshva-Pavanamuktâsana Parighâsana

6) Trunk rotation with hip flexion and side bending with hip abduction to the same side releases tension in both the backand the side of the trunk. The former position is achieved by bending to one side at the hip and rotating the trunkwhile maintaining spine extension. Movements in both poses involve the quadratus lumborum and the abdominaloblique muscles. When bending to the right, both muscles are eccentrically contracted on the left to lower the trunkto 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. Thisalso lengthens the rectus abdominus. Sequence includes: pârshva-pavanamuktâsanaand parighâsana.

7) The compressive effects of gravity on the intervertebral disc space are reversed through performance of invertedposes 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.

Rope ShîrshâsanaÛrdhva-Dandâsana Halâsana

8) The abdominal muscles (rectus abdominus, internal and external obliques) are toned to prevent anterior pelvictilt by elevating the sternum, contracting the abdominals to lift the legs off the floor, and rotating the spine.Sequence includes: jathara-parivartanâsanawith knees bent, ubhaya-pâdângushthâsanaor V-shape supportedby a chair, plus standing poses and back extensions.

Jathara-Parivartanâsana Ubhaya-Pâdângushthâsana or V-shape


Vîrabhadrâsana I Ûrdhva-Mukha-Shvânâsana Ushtrâsana

Hip Flexors Chest Muscles Upper Back Muscles

Ûrdhva-Dhanurâsana Sâlamba-Sarvângâsana Shalabhâsana

Iliopsoas and Pelvis

9) Mobility of the sacrum, shoulder girdle, and thoracic spine is increased and lumbar spine and pelvic stability isestablished in order to distribute the concave curvature in back extensions evenly throughout the spine. All theactions 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 compressionof 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 alignmentof the shoulder girdle together with increasing its mobility is accomplished by activating scapular adductors anddepressors (trapezius) to draw shoulders back and down and by lengthening pectoralis major and minor. Activeextension 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 supportedposes: vîrabhadrâsanaI at the trestler, ûrdhva-mukha-shvânâsanaon the stool or using upper wall ropes,ushtrâsanaover bolsters on the halâsanabox, ûrdhva-dhanurâsanaover trestler or using the backbender,sâlamba-sarvângâsanaat the trestler, and shalabhâsanaover bolsters.

Scientific Studies of YogaTherapy for LBP

The scientific study of Yoga is inits infancy. To date, there has onlybeen one study in a peer-reviewedjournal on the effect of Yoga on LBP.Vidyasagar et al. examined the effectof Yoga on non-specific LBP in 33

patients.14 In the 29 patients thatwere followed, 22 reported completepain relief, 5 required modificationof the therapy because of severepain, and 7 obtained no pain reliefand discontinued treatment. TheYoga intervention consisted of threephases, each three weeks long, andprimarily used classical postures

involving back extension. In the firstphase, patients practiced nirâlam-bâsanaand bhujângâsanadaily for45 minutes with 10 minute intervalsof rest in makarâsana. In the secondphase, patients practiced pâr-vatâsanaand ushtrâsana. In the thirdphase, patients practiced shalab-hâsanaand dhanurâsana. Although


the majority of patients reported painrelief, this study was not adequatelycontrolled, had a small sample size,and did not describe how pain statuswas assessed.

There are very few studies ofIyengar Yoga. However, those thathave been done have been welldesigned and have overcome someof the pitfalls of other Yoga studies.Garfinkle et al. conducted two well-controlled studies of the therapeuticapplication of Iyengar Yoga oncarpel tunnel syndrome and osteo-arthritis of the hands.15,16 Subjectsrandomized to the Yoga regime inboth studies demonstrated signifi-cant improvements compared tocontrol groups. Patients with carpaltunnel syndrome reported significantimprovement in grip strength, phalensign, and pain reduction whereaspatients with osteoarthritis reportedsignificant improvements in painduring activity, tenderness, and fin-ger range of motion. DiCarlo et al.compared the cardiovascular, meta-bolic, and perceptual responses of 10beginning subjects performing a vig-orous routine of Iyengar-style stand-ing poses to a 32-minute treadmillwalk.17 They found that heart rate,blood pressure, and perceived levelof exertion were higher during Yogathan treadmill walking, while oxy-gen consumption was higher duringwalking than Yoga. This study used avery demanding protocol for begin-ning students, and poses would nottypically be held for 40 seconds eachside with beginners.

This study examines the thera-peutic application of Iyengar Yoga inpeople with chronic LBP. The inter-vention is quite different from thatused by Vidyasagar et al.18 No backextensions were taught during the16-week Iyengar Yoga therapy pro-gram described below. Furthermore,when back extensions are incorpo-rated in Iyengar yoga therapy, they

are done using props for externalsupport. They are taught after thestudent has learned the basic actionsin standing and seated poses, inver-sions, forward bends, and twists.According to B. K. S. Iyengar, theabove back extensions used byVidyasagar19 are harmful to personswith LBP who are not trained in theintricate movements of the pose.Beginners are unable to obtain cor-rect alignment of the spinal vertebraeand musculature in the back exten-sions without the guidance of anexperienced teacher in the Iyengarmethod and without external sup-port. B. K. S. Iyengar has observedthat although there is a concaveappearance of the back bend, in theuntrained student the spinal verte-brae undergo an incorrect convexmovement, along with the muscula-ture improperly contracting towardthe vertebrae.

The current study uses a ran-domized controlled trial with sub-jects with nonspecific chronic LBPto compare Iyengar Yoga therapy toan educational control group receiv-ing weekly newsletters on topicsrelated to recovery of LBP. Both pro-grams were 16 weeks long andincluded two education sessions onchronic LBP by a physical therapistand an occupational therapist prior tothe start of the programs. Studyinclusion criteria were as follows:history of nonspecific LBP withsymptoms for ≥ three months, >18years of age, English speaking, andambulatory. Individuals were ex-cluded if their LBP was due to nerveroot compression, disc prolapse,spinal stenosis, tumor, spinal infec-tion, alkylosing spondylitis, spondy-lolisthesis, kyphosis, structuralscoliosis, symptomatic osteoarthritisor degenerating disc disease, or awidespread neurological disorder.Also precluded were pre-surgicalcandidates involved in litigation or

compensation, those who had a com-promised cardiopulmonary system,were pregnant, had a body massindex ≥ 35, and/or had major depres-sion or a substance abuse issue. Onlyindividuals who were willing tocommit to attending 14 of the 16weeks of classes (if randomized tothe Yoga therapy group) and whoagreed to forgo other forms of CAMduring the study were included. Bothgroups were allowed to continuemedical care for LBP.

The following results wereobtained from a study by Williams etal.20 Of 210 candidates invited to par-ticipate in the study, 70 (33%) metthe inclusion criteria and 60 (29%)agreed to enroll. One hundred-fortycandidates were excluded beforeenrollment for the following rea-sons: logistical conflicts (72.8%),contraindicated medical conditions(13.6%), unwillingness to forgoother forms of CAM (13.6%). Inaddition, ten (14.3%) of the 70 eligi-ble candidates dropped out beforeenrollment. Three of the remaining60 eligible subjects were excludedfollowing the start of the study dueto pregnancy, degenerative disc dis-ease, and a herniated disc. Out of 57subjects enrolled at the beginning ofthe study 42 completed the study,giving an overall rate of completionof 74%. Of the 20 subjects complet-ing the Yoga intervention, an atten-dance rate of 91.9% was achievedfor the 16-week protocol.

Of the final 42 participants whocompleted the entire study, the over-all mean age was 48.3 ± 1.5 yearswith the youngest participant 23years old and the oldest 67. Ninety-one percent of the participants in thestudy were Caucasian (N=40) withethnic diversity represented by twoAfrican-Americans (4.5%), oneAsian (2.2%), and one Native Amer-ican (2.2%). Sixty-eight percent ofthe sample was female and 32% was


male. Subjects had LBP for an aver-age of 11.2 ± 1.54 years, 48% usedpain medication, and 30% used someform of CAM for LBP. A one-wayanalysis of variance (unpaired t-test)revealed no significant differences indemographics and medical historybetween the Yoga group and the con-trol group (p> .05) suggesting thatrandomization was effective. Com-parison of baseline scores of out-come variables in the two groupsindicated that no significant differ-ences existed in the majority of vari-ables with the exception of 4subscale scores. The Yoga groupreported significantly higher func-tional ability on the self-efficacyquestionnaire (p=.005), lower cata-strophizing on the coping strategiesquestionnaire (p=.007), and less per-ceived disability (p=.002) and harm(p=.02) on the survey of pain atti-tudes questionnaire than the controlgroup.

One-way analysis of demo-graphic factors, medical history,baseline pain intensity, and disabilitycomparing subjects who completedthe study (N=42) and subjects whoeither dropped out or were lost to fol-low-up (N=15) revealed no signifi-cant between-group differences indemographics or baseline disabilityor pain intensity. However, non-com-pleters had LBP for a longer periodof time (16.4 ± 2.5 yrs) compared tocompleters (10.21 ± 1.51 yrs).

In the Yoga group, there was84% attendance of classes (includingdropouts; 92% excluding dropouts)and a 74% completion rate at thepost and three-month follow-up. Inthe control group, 80% of subjectscompleted the post assessment and73% completed the three-month fol-low-up assessment.

In the analysis of covariance thatcontrolled for baseline score, sub-jects in the Yoga therapy groupreported significant improvements in

the primary outcome and in a num-ber of secondary outcomes com-pared to the control group aftercompletion of the program. Theseinclude a 77% reduction in func-tional disability (p=.0053), 64%decrease in present pain (p=.0180),10% increase in standing hip flexion(p=.015), and 25% increase in per-ceived control over pain (p=.005). Inaddition, the Yoga group has a trendtoward greater pain tolerance topressure compared to controls at anumber of locations in the low backand pelvis. These include standardtrigger point locations for right glu-teus medius (p=.053), right ilio-costalis (p=.085), and left iliocostalis(p=.08). Between-group differenceswere only obtained in pain toleranceon the left quadratus lumborum mus-cle (p=.016).The Yoga group had a16% increase in pain tolerance at thissite after the 16-week Yoga therapyprogram. Pain medication usage wasalso significantly reduced in theYoga group compared to the controlgroup at both post and three-monthfollow-up assessments (p < .01). Inthe Yoga group, 88% of the subjectstaking pain medication for LBP atbaseline either stopped or used lesscompared to 35% in the controlgroup immediately after completionof the program.

These preliminary data areimportant for a number of reasons.They determined that the majority ofself-referred persons with nonspe-cific chronic LBP would complywith Iyengar Yoga therapy. Further-more, a significant number of sub-jects reported improvement inpain-related outcomes from a 16-week program. From the variety ofoutcomes tested, present pain inten-sity, functional disability, perceivedcontrol over pain, and hip flexionwere significantly improved andpain medication usage was de-creased by Iyenger Yoga therapy.

Surprisingly, beliefs, attitudes, andbehaviors about pain, with theexception of perceived control overpain, were not significantly differentfrom the control after the interven-tion. This may be due to the weeklyeducation of the control group abouta variety of topics related to chronicLBP including psychological andbehavioral factors. The pilot studygave the Yoga instructor and assis-tants an opportunity to test the 16-week Yoga therapy curriculum. Itwas quickly realized that the timeallotted was too short to deliver thecomplete protocol for LBP designedby B. K. S. Iyengar as describedabove and for subjects to becomeproficient in the actions and align-ment required for optimal therapeu-tic benefit. The subjects alsoexpressed that they were just begin-ning to become proficient in theposes by the end of the program andwould have liked to continue. Thusfuture studies will involve a longerprogram and the opportunity for stu-dents to practice the poses outside ofclass time at the Yoga studio undersupervision. We have submitted aproposal to the National Center forComplementary and AlternativeMedicine at the National Institutes ofHealth to continue this research.

I would like to thank all the peoplewho have helped me to understandthe therapeutic application of Iyen-gar Yoga for chronic low back pain.First and foremost, I would like toacknowledge the genius of B. K. S.Iyengar and how his deep under-standing of Yoga guided him in thedevelopment of this program. I amdeeply grateful for his suggestionsfor this article. I would also like tothank Geeta Iyengar for her guid-ance in my own recovery fromchronic low back pain at the Rama-mani Iyengar Memorial Yoga Insti-tute in Pune, India. Special thanks to


the senior Iyengar teachers (Mar-lene Mawhinney, Lois Steinberg, andManouso Manous) and Iyengar-trained clinicians who continue toteach me how to stay pain freethrough proper performance ofâsana.I would also like to acknowl-edge the assistance of DavidGoodrich, Marybeth Korf, N. Noer-achmanto, and Kirsten Dennison inthe preparation of this manuscript.Special thanks to graphic artistFrancoise Stauber for her drawingsof the musculoskeletal system per-taining to the back.

With the exception of the “Pelvis andSpine” and “Iliopsoas and Pelvis”illustrations, all musculoskeletalimages courtesy of Primal Pictures.For more information on their inter-active 3D anatomy software pleasego to www.primalpictures.com.

Endnotes

1. Druss, B. G., S. C. Marcus, M. Olfson,and H. A. Pincus. The most expensivemedical conditions in America. HealthAffairs, 2002, 21:105–111.

2. Eisenberg, D. M., R. C. Kessler, C.Foster, F. E. Norlock, D. R. Calkins, andT. L. Delbanco. Unconventional medicinein the United States: Prevalence, costs,and patterns of use. The New EnglandJournal of Medicine, 1993, 328:246–252.

3. NCCAM. Mind-body interventions. 20Sep 2003. URL: http://nccam.nih.gov/health/whatiscam/.

4. Iyengar, B. K. S. Light on Yoga. NewYork: Schocken Books, 1976.

5. Iyengar, B. K. S. Light on Pranayama:The Yogic Art of Breathing. New York:Crossroad Publishing, 1989.

6. Schatz, M. P. Back Care Basics. Berke-ley, Calif.: Rodmell Press, 1992.

7. Raman, K. A Matter of Health: Integra-tion of Yoga and Western Medicine forPrevention and Cure. Chennai (Madras),India: Eastwest Books, 1998.

8. Garfinkel, M. S., H. R. Schumacher, Jr.,A, Husain, M. Levy, and R. A. Reshetar.Evaluation of a yoga based regimen fortreatment of osteoarthritis of the hands.Journal of Rheumatology, 1994, 21:2341–2343.

9. Garfinkel, M. S., A. Singhal, W. A.Katz, D. A. Allan, R. Reshetar, and H. R.Schumacher, Jr. Yoga-based interventionfor carpal tunnel syndrome: A randomizedtrial. Journal of the American MedicalAssociation, 1998, 280:1601–1603.

10. Schatz, op. cit.

11. Iyengar, P. S. Yoga and the new mil-lennium. Yoga Rahasya,1998.

12. Steinberg, L. Iyengar Yoga Therapeu-tics: The Lower Back. Unpublished work,2002.

13. Lively, M. W. Sports medicine ap-proach to low back pain. Southern Med-ical Journal, 2002, 95:642–646.

14. Vidyasagar, J. V. S., B. N. Prasad, M.V. Reddy, P. S. Raju, M. Jayshankar, andK. Sampath. Effects of yoga practices in

non-specific low back pain. Clinical Pro-ceedings of NIMS, 1989, 4:160–164.

15. Garfinkel, Schumacher, et al., op. cit.

16. Garfinkel, Singhal, et al., op. cit.

17. DiCarlo, L. J., P. B. Sparling, B. T.Hinson, T. K. Snow, and L. B. Rosskopf.Cardiovascular, metabolic, and perceptualresponses to hatha yoga standing poses.Medicine, Exercise, Nutrition and Health,1995, 4:107–112.

18. Vidyasagar et al., op. cit.

19. Ibid.

20. Williams, K., J. Petronis, D. Smith, L.Steinberg, E. Doyle, M. Kolar, et al. Effectof Iyengar Yoga therapy on chronic lowback pain. Submitted to Pain Journal2003.

© Kimberly Williams, Lois Stein-berg, and John J. Petronis 2003

Kimberly WilliamsTel.: 304-293-7559Email: [email protected]

Lois SteinbergTel.: 217-344-YOGAEmail: [email protected]

John PetronisTel.: 304-293-1561Email: [email protected]

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