A special guest article by Paul Ingraham

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Introduction from Jenni

I feel extremely fortunate to share this special guest article with you today! For many, Paul Ingraham needs no introduction. And for those new to Paul’s work, I’m thrilled to introduce a voice that I feel makes an invaluable contribution to the evidence-based yoga, movement, fitness, and therapeutic worlds.

This is the PainScience.com salamander logo!

Paul is a science journalist who owns and operates the website PainScience.com, which is a foundational resource for anyone interested in learning about the science of pain. (And in my opinion, that should be everyone with a body! ;) ) Paul was previously a Registered Massage Therapist from 2000–2010, and he was also the assistant editor of ScienceBasedMedicine.org from 2009–2016.

I’ve followed and admired Paul’s work for years now. In my quest to share evidence-based information about the human body and movement with my yoga-based audience, I thought Paul’s voice could be game-changing for our community. I knew it was a long shot, but I reached out to Paul and asked if he was interested in writing an article about yoga for my blog. I was overjoyed when he said yes(!!), and from the list of potential topics I provided, he chose the topic of today’s piece: yoga for low back pain.

To help plant some seeds for this article, I shared a list of questions with Paul about this big, nuanced topic.

My questions revolved around three themes:

Does scientific evidence suggest that yoga can help with back pain?
If yoga can help with back pain, does it help through specific, intrinsic, yoga-based qualities? Or does it work via general, nonspecific effects – much like exercise and movement in general are helpful for back pain?
Are “Yoga for Back Pain” classes evidence-based?

Paul has expertly woven his responses to these questions into his overall article. (And he’s added a lot more, as well!)

When you read this piece, I think it’s important to keep in mind the distinction between a general yoga class helping with back pain in a nonspecific way, and a “Yoga for Back Pain” class that’s intended to treat back pain in a specific way.

I’ll circle back after the conclusion of Paul’s article below to offer some closing thoughts and practical takeaways .

Without further ado, here is Paul’s article!

Yoga has no “active ingredient” for back pain

by Paul Ingraham

Learn more about back pain from Paul in his e-book The Complete Guide to Low Back Pain.

In my first year as a Registered Massage Therapist in Vancouver in 2000, I had not yet turned into a curmudgeonly skeptic, but there were early warning signs. I went to an Iyengar yoga class, billed as therapeutic for patients with pain. A mentor had told me it was an advanced class, ideal for healthcare pros, a kind of continuing education.

I was not impressed. I saw problems. I started nitpicking in my head, and I interrupted the instructor to correct her on a point of anatomy. “Actually…”

Yes, I was that guy: I tried to publicly mansplain anatomy to a yoga instructor the first time I attended her class. But it gets worse! I also got it wrong, despite warning myself to be careful. That memory still burns more than twenty years later.

But here’s the thing: I was right in spirit! Not on that anatomical detail — I surely did screw that up — but I was right about the big picture, right to be underwhelmed and annoyed by the “therapy theatre.” Because most of that “advanced” content was bogus and mostly irrelevant to any kind of pain.

If I’d said, “Actually, yoga has no special active ingredient that is good for back pain,” I would have been right. Obnoxious! But correct.

Does yoga help back pain? I have bad news and less-bad news

Most people assume that yoga is good for back pain, but is that true? Is it “clinically proven”? When tested rigorously, when you filter some of the noise out of the data, do back pain patients get results from yoga?

This question is plagued with a good-news-bad-news answer. Or maybe a bad and less-bad answer. The answer depends entirely on what you’re comparing yoga to.

If you mean “does it work better than nothing,” well… maybe. According to the science, yoga might be a little bit more helpful than doing no other kind of exercise or therapy, but it’s not nearly as clear as we’d all like it to be. That’s the less-bad news.

But if by “work” you mean “does it work better than other kinds of exercise” — is there something special about it — the answer is a major blow to yoga pride. Yoga doesn't even get a lousy “maybe” from science on this question. The evidence is blunt: all exercise, including yoga, is equally mediocre therapy for back pain.

Citation needed, of course. So I brought the science…

Science isn’t even quite sure that yoga is better than nothing

Many scientific studies declare yoga effective compared to doing nothing,¹ but the best ones aren’t so encouraging:

The Cochrane Collaboration, purveyor of fine meta-analyses (pooling data from many studies), is an organization that is notorious for pulling their punches.² But on yoga for back pain? A 2017 paper from Cochrane crushed yoga hopes more than usual, concluding that it has no meaningful benefit … compared to nothing. There’s plenty more-study-needed uncertainty too, but the paper is a surprising bummer from this particular source: they acknowledge some short-term benefits, but they also make it clear they were trivial.³
A 2022 review reported the same small effects without bothering to say they were trivial, but it’s right there in the data. How much did yoga help with pain, temporarily, compared to “nothing”? Less than a point on a ten-scale.⁴
Or there’s the 2020 meta-analysis that concludes that yoga “might” be helpful.⁵ Not exactly a ringing endorsement.

Yoga versus other exercise & therapy

Millions of people assume that yoga is special in some way, better for backs than any other common form of exercise, or at least most of them. Alas, science unanimously declares yoga to be the loser here. No cherry-picking required.

The 2022 study above was quite positive about yoga-versus-nothing, but strongly negative on yoga-versus-exercise: “Not associated with any significant differences.” Translation: epic fail.
A 2021 trial — a pretty good one in the journal Journal of Pain — compared yoga to both physio and eurythmy (a kooky movement therapy and/or performance art). All had equally trivial benefits.⁶
But who needs quality and objectivity? Even the Journal of Alternative and Complementary Medicine — not exactly known for publishing discouraging words about alternative therapies — concluded that yoga is no better than other exercise.⁷
One study even found that yoga didn’t even help anxiety and depression in back pain patients.⁸ This undermines the hope that the socialness of yoga is important.
A widely cited 2011 trial found that yoga was no better than stretching for back pain … and neither was all that good.⁹
Maybe yoga is better than pumping iron? Not according to the a 2017 trial.¹⁰

And so on. There are no important exceptions to this theme in the research.

Buts! The two main objections to the science

Yoga teachers, as a breed, are not always known for their love of science, and many will scoff at the studies for two legitimate reasons:

They didn’t study the right kind of yoga. Here’s the thing: Researchers are not fools. They don’t get their yoga teachers from a dollar store, and what they are studying is mostly pretty decent yoga. But of course it is possible that some yoga works better for back pain, and this has been missed.
They didn’t study the right kind of back pain patients. And of course this is also possible — almost certain, in fact — that yoga works better for some kinds of patients than others.

But these concerns about the research have serious theory-versus-practice problems. No one knows what the better yoga is, or who the right sort of patients are. And, even if the smartest of smartypants actually did know, they would be one voice in the wilderness. Most yoga in the real world would carry on being mostly the wrong yoga for mostly the wrong people, with mostly mediocre effects and just a sprinkling of both success stories and bad outcomes at the edges of the bell curve.

Only one active ingredient of yoga is taken seriously: the core exercise

Yoga contains multitudes, and maybe it’s good exercise because of the prana, or the socializing, or the mindfulness, and people enjoy speculating about what the active ingredients might be. But almost all yoga for back pain is mostly very physical. You don’t see advertisements for Tantric or Jain yoga for back pain. You don’t see a half-dozen yoga studios in every city claiming that Hindu spiritual teachings are what makes jivamukti yoga work for back pain.

No, it’s always the hatha yogas, the most secular and fitness-focussed, especially the Iyengar and Vinyasa traditions. Everyone thinks yoga is good for back pain specifically because it’s good for your core strength and coordination, and more generally the “optimization” of posture and spinal alignment.

This is why nearly all yoga studios preach the core exercise gospel. Unfortunately, it’s not true.

“Does yoga work” is basically the same as asking if core training works, and we already know the answer to that. We can infer it from all of the evidence about yoga, but there’s also an avalanche of data about “core” fitness achieved by many other means. The science of core training is too mighty a topic for this article, but I explore it all in detail in my back pain book.

Back pain is mostly not a “biomechanical” or “structural” problem

The gospel of core exercise is the solution to a largely imaginary problem, fear mongering about a mostly obsolete and simplistic view of back pain that has been debunked by back pain experts and undermined by the science for decades — mostly based on the strong evidence that people routinely hurt without spinal problems, and vice versa.

But the myth marches on, barely dimmed — thanks in large part to yoga!

Yes, some back pain is structural in character, and we shouldn’t throw those babies out with the bathwater. But the last thing most of those cases need is yoga. (And, even if spines needed changing, or more “support,” yoga does not do it.¹¹)

Meanwhile, there are many other more common and important drivers of back pain: messy biochemical and sensory factors instead of biomechanical. The most important thing to understand about back pain is that it rarely has one clear mechanical cause.

Can yoga-for-back-pain classes still help people? Yes… but they can also hurt!

Yoga is a nice way to exercise, and that can help many people. It’s not gargling bleach or psychic surgery. But is teaching yoga to back pain patients better than not doing it? I don’t think so: not enough people will be helped, but the real deal-breaker is that too many will be harmed, both directly and indirectly.

An awful lot happens in yoga classes that seems like it could be a bad idea if you have back pain. But what cannot help much usually can’t hurt much either, and science confirms it: serious harm from competent yoga instruction is extremely rare.

But exercise can backfire, and so can yoga. Worsening back pain is common.¹² In one trial, pain increased in 12 of 156 people.¹³ So one or two people in most classes will get worse — which, at the scale of the yoga industry — is millions of people getting the opposite of what they wanted.

And how many more will learn to be fearful of their supposedly fragile spines? Scared of not being “aligned” enough? Yoga classes for back pain are little fear factories, selling the solution to a mostly imaginary problem — a quarter-truth at best. I wish I never had to meet another person who has gotten obsessed with the supposed importance of posture and spinal alignment, convinced that a lapse in vigilance will trigger an episode of back pain. Unfortunately, I know that I will meet many.

Are yoga teachers qualified to treat low back pain?

You can’t diagnose spinal tumours or infections from the front of a yoga class, which is basically why yoga instructors are only barely qualified to teach yoga to back pain patients, but never for back pain. There are many causes of back pain, and some of them are scary, so the minimum qualification to help people with back pain is being well educated about red flags (and also having the time for discussion and examination).

Is it possible to teach an evidence-based “yoga for low back pain” class? Are yoga teachers qualified to treat back pain?

Yes, it’s possible to teach an evidence-based “yoga for low back pain” class. But it would be a strange and ironic class! Done right, it would undermine its own purpose, while providing what people actually need: some relief from the false hopes, red herrings, and nocebos provided by so many others. There are many back pain myths, yoga’s value for back pain is one of them, and debunking is effective.¹⁴ And why not have a class so humble that it’s almost laughing at itself? Seems rather Buddhist, actually. The right kind of students will find all this very refreshing… and yoga is still going to happen, and that’s still a good thing even if it’s not a “special for back pain” thing.

Closing Thoughts From Jenni:

I think this article is important for the yoga community for a number of reasons.

On one hand, it might be disappointing to learn that science does not support the notion that yoga contains a special ingredient that makes it specifically healing for back pain.

But on the other hand, I think it’s actually encouraging to learn that science does support yoga as being about as helpful for back pain as exercise in general. This means that for those of us who feel motivated to use an active strategy to help with back pain, we have many options from which to choose! And if we happen to love yoga (which many people do), then yoga can be an excellent option for us – especially because we’re more likely to stick with a movement modality that we enjoy.

I’d also like to offer some additional thoughts on whether “Yoga for Back Pain” classes are evidence-based.

In my experience, most “Yoga for Back Pain” classes are not evidence-based. That’s because they tend to focus on biomechanical causes and solutions for back pain (as Paul discussed so well in the article).

However, if “Yoga for Back Pain” classes instead embraced a biopsychosocial approach to back pain, I think they could be evidence-based.

But ultimately, I don’t see how a biopsychosocial-informed “Yoga for Back Pain” class would look different in practice from a general yoga class that wasn’t specifically focused on back pain. In order to be evidence-based when it comes to pain, a yoga teacher mainly needs to avoid unhelpful biomechanical narratives and nocebos and allow the yoga they teach to work its nonspecific “magic” on students.

This doesn’t require anything more specific or specialized than creating a supportive and positive environment for yoga students to move, breathe, and pay attention to their body.

If a true evidence-based “Yoga for Back Pain” class looks no different from an evidence-based general yoga class, is the specific “back pain” title necessary or helpful?

Could embracing the nonspecific, positive effects that yoga can offer for back pain be freeing and empowering because we aren’t limited to narrow ideas about “Yoga for Back Pain” needing to be taught in a specific way?

I appreciate thoughtful articles like Paul’s because they do a great job of leaving us with as many questions as they do answers. I hope this piece offers you some insightful questions that help inform your perspective on how we can be helpful as yoga teachers – specifically with regard to students with back pain!

Related: Listen to Paul discuss this article and yoga and low back pain in general on Episode 30 of the Yoga Meets Movement Science podcast!

About the Author

Paul Ingraham is a Vancouver science writer and a former Registered Massage Therapist. He left that profession over concerns about pseudoscientific beliefs and practices, and went on to create PainScience.com, a website about the science of pain, injury, treatment, and rehab, where he has published hundreds of articles and ten books on these themes, the longest of which is about back pain. He's also a reluctant runner and an avid ultimate player (the Frisbee sport) with a long list of his own sports injuries and pain problems. Although not currently blessed with pets, he has shared his life with both a dog and a cat in the past. He is working on his next book and endless updates to PainScience.com.

Paul’s website: PainScience.com

Paul’s e-book: The Complete Guide to Low Back Pain

About PainScience.com / About Paul Ingraham

Notes

Cramer H, Lauche R, Haller H, Dobos G. A systematic review and meta-analysis of yoga for low back pain. Clin J Pain. 2013 May;29(5):450–60. PubMed #23246998 ❐ This is a great citation for yoga studios to put on their bulletin boards: “strong evidence for short-term effectiveness and moderate evidence for long-term effectiveness of yoga for chronic low back pain.”
Cochrane is actually a bit notorious among skeptics for never actually arriving at a richly deserved negative conclusion, because more study is always allegedly needed. This is exploited by cranks and quacks who spin it as a meaningful absence of evidence. “So … you’re saying there’s a chance!” And the Cochrane reviews reply, “Technically, we cannot crush your hopes at this time.” And so evidence-based medicine weirdly manages to give a kind of a pass to all kinds of dubious remedies and therapies. That is not really how EBM was supposed to work.
Wieland LS, Skoetz N, Pilkington K, et al. Yoga treatment for chronic non-specific low back pain. Cochrane Database Syst Rev. 2017 01;1:CD010671. PubMed #28076926 ❐ Yes, “yoga compared to non-exercise controls results in small to moderate improvements in back-related function.” But! “The effect size did not meet predefined levels of minimum clinical importance.”
Anheyer D, Haller H, Lauche R, Dobos G, Cramer H. Yoga for treating low back pain: a systematic review and meta-analysis. Pain. 2022 04;163(4):e504–e517. PubMed #34326296 ❐ It’s a common bit of jiggery pokery in science to fail to point out small “effect sizes,” and this is a perfect example.
Zhu F, Zhang M, Wang D, et al. Yoga compared to non-exercise or physical therapy exercise on pain, disability, and quality of life for patients with chronic low back pain: A systematic review and meta-analysis of randomized controlled trials. PLoS One. 2020;15(9):e0238544. PubMed #32870936 ❐ Zhu et al introduce their paper with the bold premise that “Yoga has been proven to be an effective therapy for chronic low back pain.” Really? Because that same paper concludes that the benefit of yoga compared to not exercising is so minor that the best you could say was that it “might” be superior. “Might be better” and “proven” do not belong in the same abstract! So the “proven” benefit is getting into DWFP territory — “damned with faint praise,” so common with back pain treatment that I wish I could get away with abbreviating it with no explanation.
Michalsen A, Jeitler M, Kessler CS, et al. Yoga, Eurythmy Therapy and Standard Physiotherapy (YES-Trial) for Patients With Chronic Non-specific Low Back Pain: A Three-Armed Randomized Controlled Trial. J Pain. 2021 10;22(10):1233–1245. PubMed #33892154 ❐
Neyaz O, Sumila L, Nanda S, Wadhwa S. Effectiveness of Hatha Yoga Versus Conventional Therapeutic Exercises for Chronic Nonspecific Low-Back Pain. J Altern Complement Med. 2019 Sep;25(9):938–945. PubMed #31347920 ❐
Joyce C, Roseen EJ, Keysor JJ, et al. Can Yoga or Physical Therapy for Chronic Low Back Pain Improve Depression and Anxiety Among Adults From a Racially Diverse, Low-Income Community? A Secondary Analysis of a Randomized Controlled Trial. Arch Phys Med Rehabil. 2021 06;102(6):1049–1058. PubMed #33556352 ❐
Sherman KJ, Cherkin DC, Wellman RD, et al. A Randomized Trial Comparing Yoga, Stretching, and a Self-care Book for Chronic Low Back Pain. Arch Intern Med. 2011 Oct. PubMed #22025101 ❐
Brämberg EB, Bergström G, Jensen I, Hagberg J, Kwak L. Effects of yoga, strength training and advice on back pain: a randomized controlled trial. BMC Musculoskelet Disord. 2017 03;18(1):132. PubMed #28356091 ❐
Telles S, Bhardwaj AK, Gupta RK, et al. A Randomized Controlled Trial to Assess Pain and Magnetic Resonance Imaging-Based (MRI-Based) Structural Spine Changes in Low Back Pain Patients After Yoga Practice. Med Sci Monit. 2016 Sep;22:3228–47. PubMed #27619104 ❐ This unusual 2016 study actually measured changes in the spine itself — and finding none at all. Incredibly, the experiment required an hour of yoga per day for three months — a lot of yoga! It does seem like it might take quite a large dosage to have a measurable effect on the spine. Unfortunately (but unsurprisingly), the regimen “did not alter MRI-proven changes in the intervertebral discs and in the vertebrae.”
Wieland 2017, op. cit.
Tilbrook HE, Cox H, Hewitt CE, et al. Yoga for chronic low back pain: a randomized trial. Ann Intern Med. 2011 Nov;155(9):569–78. PubMed #22041945 ❐
Viana da Silva P, Kamper SJ, Robson E, et al. 'Myths and facts' education is comparable to 'facts only' for recall of back pain information but may improve fear-avoidance beliefs: an embedded randomized trial. J Orthop Sports Phys Ther. 2022 Jul:1–29. PubMed #35802818 ❐