Approximately 25 years ago, when I was assisting my father with clients, I once asked him, “How would you work with a person who comes to you with back pain?”
He gave me this simple algorithm/protocol:
- Yoga is about decreasing duhkha (suffering), so don’t worsen the pain. Also, that is not safe.
- Start in a comfortable position, usually resting—lying on the back for instance.
- The person will often be more comfortable in flexion or extension, so try bending the knees and place the feet on the ground (mild flexion) or apanasana (more flexion) and stretching the legs (mild extension) or dvipadapitham (bridge pose, more extension). See where the person is more comfortable and start from there.
- Gradually do movements that take the person in the opposite direction and in other axes (rotation and side bending) also.
- Usually, emphasize strength more than stretch because people work their back too little and it is weak e.g. dvipadapitham (bridge), bhujangasana (cobra), shalabhasana (locust), raising an arm or leg in cakravakasana (hands and knees), and in partial ardha uttanasana (a partial half-forward fold, which is usually done with a long/neutral spine in Krishnamacharya’s teaching, so it makes your back muscles work).
- Always move slowly with steady breathing and a calm mind—this goes without saying in Krishnamacharya’s approach to hatha yoga that my parents learned.
Many years after that, after I had finished my medical studies, I was at a yoga therapy conference where I noted that working with a problem like fatigue, whether it occurred on the background of heart disease, cancer, or multiple sclerosis was largely similar. The medical diagnosis matters less; the experience of the person matters more. As a yoga teacher/therapist, when we see someone fatigued, we help them find a way to rest—the skill of deep relaxation to facilitate recovery. The diagnosis only offers some pointers (e.g. in more advanced heart failure you may want to avoid elevating the legs) but it does not decide most of what you would do.
Returning to the issue of back pain, what can you do for a client with back pain as yoga therapist? You do not offer drugs or surgery or manual therapy. What you do is to teach self-care skills. No matter what style or ideology of yoga you belong to, these skills that the person practices are the final pathway through which the yoga takes effect.
Years ago, it became increasingly clear to me that teaching diagnosis-based yoga courses would lead a lot of overlap between them; the same skills would repeat with some modifications. Logically, a medical diagnosis-basis is a misleading and inefficient approach for a yoga therapist.
A medical label is often tied to measurements and parameters that we do not specifically influence through yoga. For instance, if you have a lumbar intervertebral disc herniation, does it matter whether it is L5-S1 or L4-L5? It certainly does if you’re a surgeon. If you’re a yoga therapist, it does not. You will not teach the person anything different based on that information. Perhaps half of middle-aged people will show cervical spine degenerative changes as a radiological finding on an MRI. It correlates poorly with pain. That label is radiological, not functional. That label should not influence your clinical choices as a yoga therapist; assess the function or skills of the person and make your decisions.
No matter what the cause of back pain is, what you can do ultimately as a yoga therapist is to teach them wellbeing skills: find a pain-free position, bring awareness to your back, start by moving in a safe range, massage the tissues and release them, gradually strengthen the muscles, bring the spine to neutral alignment, stabilize the spine, do some traction, repeat these skills and do them in your daily life too if possible. Send the back some positive thoughts and feelings and encourage confidence (you can do this for any part of your body in pain).
You will mostly teach similar skills regardless of what diagnosis the person receives—because this is what you can do in your scope of practice. What a diagnosis gives you, and only sometimes, is some extra suggestions: if the client has sciatica (nerve pain down the leg from sciatic nerve compression), do movements that centralize it (decrease the spread of the pain down the leg); usually extension (backward bending movements) help. The rest of the algorithm or skills-based protocol remains the same. Non-specific back pain, lumbar disc herniation, facet joint subluxation, facet joint arthritis, spondylolisthesis, spinal stenosis: all these labels give you some clues on modifying the emphasis on different skills you teach to the client, but much more depends on the experience of the client.
What if you don’t have back pain, and still practice these wellbeing skills for your low back? That is a good idea—you will develop a moat of resilience and the chance of your developing back pain significantly decreases. So, an approach based on wellbeing skills has equal relevance not just to therapy but also to prevention and enhancing wellbeing.
After many years, I have come the full circle—having satisfied myself that best wellbeing system is based on the wisdom of yoga skills, derived from the wisdom and intelligence of sages such as Bhagavan Patanjali and earlier, to more recent luminaries like Sri Krishnamacharya and Swami Hariharananda Aranya. That wisdom has been refined further and brought to me and so many other students of Svastha through my parents, from their deep yoga studies and practice, and their work benefiting thousands of students.
This leads me to the ultimate question that has challenged me for many years. What should we basea yoga diagnosis on? The best answer to that question is: a yoga diagnosis analyses the person based on the imbalances of function, which directs us to the skills we need to restore balance. Therefore, I have worked for years to present an expanded skills map that is also a comprehensive, effective, and accessible yoga diagnosis system.
Look at the expanded Svastha syllabus and ask yourself simply: what skills would make me feel more well? This is the main line of thinking of a yoga therapist: when you come across a modern diagnosis, ask, “What imbalances does this point to, and which skills will balance them?” Analyze the imbalances based on the map of skills. Following this approach, you can easily translate a modern medical diagnosis into a holistic skills diagnosis (i.e. a yoga or self-care diagnosis), and a yoga therapy protocol or practice can be easily and reliably devised and delivered.
The other key feature of the Svastha system here is that these skills are a universal map: they are not restricted to a style or tradition. All yoga schools and systems can and should use at least this set of skills to cover the person holistically. All yoga schools can agree with this map; the skills are based on the reality of the person, the science is key textbook medicine, and the traditional concepts are the foundational ones from major yoga and ayurveda sources.
This reaches another wonderful goal: to offer a neutral, deep, and reliable pathway to unite more yoga teachers and therapists. It also opens the door for more of the Svastha community to teach yoga therapy to students effectively, and to participate in delivering the Svastha yoga therapy program itself.
Much more is coming! 🙂 Thank you for reading. 🙏
Dr. Ganesh Mohan