Demystifying Low Back Pain

Um a real honor to deliver this um Workshop to you all today I remember as a child my mom having very severe episodes of low back pain and it felt really frightening so back pain for me as a child felt like this really really scary thing and it's been lovely as an adult to really do a deep deep dive into all of the latest research um into this and actually to come it from a much more empowering Perspective so I'm excited to share some really wonderful information with you today and it's also great to know

that often yoga back um lower back pain isn't quite as scary as as we might think it is and there are a lot of things that we can do for ourselves and for our students that can really help here so it's a it's a really lovely to be able to share this all with you so a little um cartoon that I came across and would you might just maybe let me know in the Chat give me a thumbs up or something to know that you're now able to see the presentation that would be really great

and can just be fully present be great lovely okay fantastic so it's for my back you have two more questions all right so um there's some um research that tells us that when we um know what we're going what information we're going to receive we're more likely to actually receive that Information so I'm going to share with you the aims and objectives for today we're going to quickly review the anatomy and physiology of the lumber spine I know one of you said so that you really want to hear more about the SI joint The secc

Joint email me and I'll send you some great information on that we just are not going to be able to cover in detail today there's just too much to talk about we're going to G gain a contemporary evidence-based Understanding of pain science we're going to apply What's called the bioc psychosocial model to low back pain we're going to discuss whether things like tight hamstrings weak glutes weak core poor posture can actually cause low back pain I hear all this stuff all the time let's we're going to at the science behind this we're going to look

at the current physical activity guidelines for low back pain all kind of really brilliant backed up with science we're Going to look at how yoga can impact low back pain we're going to highlight top tips for teaching yoga to a student with low back pain yeah so we're going to cover a lot today so some things to consider enjoy the workshop do not expect to remember everything we're going to cover a lot of information um you know even if you're joining live make use of the replay um receive a list of all the references so

all the scientific studies that I mentioned You'll receive that in a document so you can dive into that in more detail if you're interested and I'm also going to give you a a PDF of this presentation so you can make notes but don't feel like you have to write everything down I'm going to encourage you to take time after this webinar to reflect on the content and write down five things you want to take away with you and by discussing these five things with someone else in your life there's a Really good chance that you

will retain that information yeah so just to manage expectations you're not going to remember everything from today and just a bit of a quick disclaimer this is an educational Workshop um aimed at updating yoga teachers that should say are um low back pain and not arthritis so I need to change that you know I I have a medical degree I've worked as a doctor but I'm no longer registered as a doctor so this information doesn't Equate to medical advice you must consult a healthc care professional before implementing any of the activities that we talk about

yeah so just make sure that you take care of yourself in that respect now in any learning environment there's certain lenses that can get in the way and stop us from actually receiving information so you may have may not have heard of these before confirmation bias is essentially when We're so focused on the information that confirms your pre-existing belief that we ignore all the other information out there that might challenge that yeah so um you know even if even if a topic feels familiar to you that we covered today just be open to maybe hearing

it in a different way or with a different analogy or related to get in a different way yeah and then cognitive dissonance is when we purposefully reject any information that does not confirm or Pre-existing belief so I I'm probably going to say some things today that challenge some of your pre-existing beliefs beliefs I'm not here just to trigger you on purpose but um you know I'm going to hopefully present things in a logical way and I'm going to back everything up with science so if you feel a bit um constricted at certain points you think

oh God this this isn't what I've been told before see if you can just soften and breathe into that And you've got a greater chance of actually learning something today and here's a little um cartoon that I came across for that right so just to quickly mention you know the scope of practice for a yoga teacher most of us are going to be General yoga teachers it's not our job to cure students of their back pain okay the most important thing we can do to improve our back pain or help others understand theirs begins with

l language And mindset this is so so powerful language and mindset that Journey starts with understanding our anatomy and physiology and contemporary p and science so that's what we're going to begin with today so we're going to very briefly just do a recap of spinal Anatomy so the structures that form the spinal column must be rigid enough to support the trunk and the limbs strong enough to protect the spinal cord that passes through it and anchor the Deep SP Muscles and yet sufficiently flexible to allow for movement of the trunk in multiple directions just take

that in for a moment this amazing part of anatomy has these three separate kind of functions and it works perfectly you know doing all of this most of the time it's really quite quite remarkable it's kind of a feat of engineering okay so our spine is just amazing the curves of the spine make the structure particularly stable so that's Nice to know allowing for the distribution of body weight and the absorption of shock helping with balance and facilitating movement so the actual individual vertebrae also are involved in the production of red blood cells and platelets

like how crazy so that's another function we're going to add on to those other three pretty incredible so we have these deep spinal ligaments okay they connect the vertebrae together and along with some of the deep spinal Muscles that we're going to touch on they control and limit movement of the verbal column okay there are three ligaments and they run the entire length of the spine so we're going to very briefly touch on this so this this is the front of the spine and this is the back of the spine and we have a ligament

that runs the whole length of the spine and this is the anterior longitudinal ligament it's going to limit how much you can back bend or extend your spine It's going to add a lot of support to the spine okay so have that lovely visualization of this strong ligament running the entire length of the front of your spine and then there's a part of the back here that's been chucked off but basically there's a ligament that runs along the back of what are called the vertebral bodies of the spine okay and this is the posterior longitudinal

ligament it's going to limit how much you can flex your spine and that's a Good thing we don't want to be like an elastic band we want to have limits to what we can do yeah so again lovely visualization adding so much support here okay and then there's actually if if you um tuck your chin in and feel the little bony Parts at the back of your neck that stick out these are the spinus processes there's actually a ligament that runs along connecting all of those spinus processes okay and this is the super spinus ligament

it's also going to Limit to a certain degree how much you can flex your spine so that's a good thing and then there are also these tiny ligaments that run in between each of the adjacent vertebrae here okay and these are called the ligamentum fum so just really a beautiful visualization of how supported our spine is at the deepest level okay and then we have these amazing introver vertible discs that sit between the spine okay so they're cartilagenous and they're Actually articulating structures so they help with movement okay so they have the the Dual role

of providing the primary support for the vertebral column while also possessing enough elasticity to permit the required mobility of the spine again just kind of mindblowing when you really take that in the diss actually kind for up to 30% of our height of the spine okay and we're tallest first thing in the morning so if you ever need to measure your he do First thing and then the discs actually become less plump with gravity during the day and that's actually a good thing because the more plump the dis is the less it's actually able to

um absorb shock okay so the the less as plump it becomes it's able to actually adapt better to the demands placed on it okay so that's something of interest and then overnight it'll become plump again so it's this this this this like cycle of compression and then decompression that Naturally happens for all of us so a little bit more detail about the dis they're made up of this Central gelatinous nucleus pulposis often is refer to as NP so you'll see it here in the center and it's I'm surrounded with this tough but elastic anulus fibrosis

the AF and then you'll see this little end plate here that connects um the the dis into the vertebra itself so the the AF um is mostly avascular meaning it has very limited Blood supply only the outer third of the dis is inovated by nerves actually okay um so that's something of Interest which we'll touch on later and collagen fibers continue from the anolis fibrosis into all the adjacent tissue so this isn't a separate entity that's on its own Island this it's interwoven with all the other structures around it so it ties it to the

vertebral body to the ligaments that we've mentioned and you know also to the and plates and everything so it's it's All interwoven with the rest of the spine so don't think of it as a separate thing that can kind of slip out of place that's not a helpful image and then the nucleus proposes the center part is the self-contained pliable gelatinous structure and it has no blood supply or nerve Supply yeah so April says please send information concerning SI joint in sacrum to us participants I will do that I will create something and send it

with The followup email okay so the introvert discs are essentially hydraulic systems they provide support they separate the vertebrae they absorb shock they um permit transient compression and they allow for movement like how amazing we're going to touch on those um a little bit more in detail later okay so we're going to do a quick self test you can reflect on this personally or you can share in the chat we've got Britney Spears here to help us um so first question is the posterior longitudinal ligament so think of it being at the back of the

spine it's attached to the back of the vertebral bodies Which movement of the spine is it going to limit if it's at the back of the spine yeah well done well done D it's going to it's going to um help you to limit flexion of the spine yeah great well done AAL okay fantastic the intral discs have the Dual Role of providing the primary support for the verbal column while possessing enough elasticity to permit the required water of the spine what are they also going to help facilitate well done Mary what else they going to

help with here so the answer here is movement of the spine yeah they're going to support they're going to actually also help facilitate movement which is pretty amazing so is this true or false the Invertible discs count for about 10% of the overall height of the spine yeah well done that's false that's up to 30% and then the nucleus pulposis the central part of the disc has no what or what Supply so what is it not going to receive directly here can you remember well done no nerve or blood supply that's that's something of note

yeah okay fantastic okay so now going a little bit more superficial on top of the ligaments we have this deep set of Muscles that are here to provide support to the spine okay they're beyond our conscious control okay but they're going to they're going to act they're going to engage any time we move the spine okay so we don't have to go into all the details of the the names of this but like look at this one here there's like a plat like formation so this is running from the spinus process of one vertebrae down

to what are called the transverse processes bit stick right to the side of A vertebra it's maybe three or four beneath it's this beautiful plot the whole length um the multifid here running along the length and then we also have these muscles called the rotators so this beautiful idea with these deep strong muscles that are there to support the spine they're beyond our conscious control okay so while all these muscles are weakly involved in different spinal movements they're mainly involved in Stability and alignment of the vertebrae and the invertebral discs okay and there's some research

back in the early '90s that find that M that one of the group The multifidi account for more than 2third of the stiffness of the spine when in a neutral position so they're really adding stability here okay and then on top of those muscles we have muscles called the erector spiny sometimes referred to as the paraspinal muscles um they're really interesting so Most muscles in the body are Sprinter muscles they turn on and they turn off but the erector spine are like marathan runners okay so as as soon as um you sit up out of

bed in the morning they're switched on so they help maintain static equilibrium of the trunk and they resist flexion that would be caused by gravity you know so they help to keep you upright so they're pretty amazing they have these slow twitch fibers that are associated with endurance yeah so pretty Cool and then we have the transverse abdominis you know that's that's the next layer you know we're we're not going to go into the the specifics of the core muscles too too much in detail but we have this amazing muscle that acts like a COR

that runs around the spine and if you place your hands either side of your waist and cough you'll feel a contraction now really interesting there is this very famous Anatomy book and they basically um looked at all the research and the transverse abdominus is absent or fused to the internal obliques that are another set of core muscles on top as a normal variation in some individuals so some of you at home may not have a separate transverse abdominis and it it will have no impact on your health yeah so you know very very interesting we'll

come back to the core muscles a little bit later so messages so far the Lumar Spine is a strong and resilient part of our anatomy okay it is supported by many deep ligaments connective tissue and layers of muscles by changing the way we view this region of our body we can change our experience so many people think of their lower back as being inherently weak or inherently damaged okay and that's just not the way our body works okay yes low back pain is very prevalent in our in our society but it doesn't mean there's something

Inherently wrong with the anatomy of this part of the body this is a strong resilient part of the body okay and when we really really understand that and really embody that it can change the experience we have particularly with low back pain okay so let's let's define pain and one definition is an unpl Pleasant sensory and emotional experience associated with actual or potential tissue damage or described in terms of such damage so that's that's Interesting we'll dive into that in a little bit more detail again you you'll get a list of all these references if

you want to look into it in more detail so low back pain is the number one cause of disability in the world the lifetime prevalence is reported to be as high as 84% so the chances are that the majority of us will experience low back pain at some point in our life and in Western countries anywhere between 4 to 33% of the adult population are experiencing Low back pain at any given point so a lot of people are experiencing low back pain a lot of the time basically um you know there are different ways to

classify low back pain this is one way of classifying it can be associated with another specific spinal cause maybe cancer or a fracture this may be caused by osteoprosis or infection okay um it could be associated with radiculopathy which is basically you have a pinching of a nerve and you're getting like nerve Pain but the main category is called non-specific low back pain where there is no known pathoanatomical cause and this is approximately 85% of all cases and there's actually some more recent research that's telling us this is more closer to up to about 95%

you know so the vast majority of cases of low back pain there's no um clear anatomical reason why it is happening okay so that's definite of Note so it can be described as acute if it's less than six weeks Subacute if you're having low back pain between six and 12 weeks and then chronic if it's over 12 I personally don't enjoy the word chronic chronic to me means permanent Nothing in life is permanent even if you're getting very persistent back pain you'll have good days and bad days you have moments where you don't feel pain

and then other moments where the pain is bad so I like to think of it As persistent rather than chronic chronic feels like it's something have and you're always going to have it and there's nothing you can do about it and that's not the case in the vast vast vast majority of cases and then just something to mention you know there are certain risk factors called red flags that can help clinicians spot maybe emergency cases that need to be looked at so if you're under the age of 18 or over 50 and you're experiencing back

Pain it might need to be um looked at a little bit more closely if you're taking anti-coagulants like warin or even aspirin in some cases um you know if you've had fever back pain you know so there's there's all these different things if you had recent trauma and you back pain it needs to get looked into you know in in a much closer detail so just some red flags that U medical professionals kind of will will will check off their list um Really so this is interesting so less than 4% of people seen for low

back pain in kind of a primary care scenario have compression fractures from say o um from osteoporosis and less than 1% have a tumor um there you know spinal infections and something called ankos and spondilitis are even more rare than that and herniated discs only count for about 4% of low back pain cases this might surprise a lot of you I think there's so much talk out there about Herniated discs you might think well you know they're the cause of so many cases of low back pain it's only 4% based on the research that we

have okay so it's not quite as big a problem as many people might imagine pain is complex okay pain and tissue damage do not always correlate like how how how interesting the longer a person experiences pain the weaker the correlation with tissue damage so if you're if you've been experiencing back Pain for like three months the chances that it's coming from actually tissue damage in the lower back it it gets less and less with time okay so it is very possible to have tissue damage without experiencing pain and it's also possible to experience pain when

there's no apparent tissue damage you've had all the scans and all the the the the tests and there's no tissue damage nearly every condition we assume to be a sign of dysfunction so Think of all the chat of poor posture tightness of this muscle weakness of this part of the body degeneration they can exist some people but there's no pain okay so you know really really interesting so no receptors they're a specific type of receptor they're found in the VIS and the bones the muscles the skin and different sensor organs they respond to potentially harmful

stimuli okay um danger messages are not pain they're simply nerve impulses sent from Those little receptors in the body to the central nervous system and what's fascinating is our brain doesn't detect pain it makes it it detects potentially harmful stimuli and as a result it can generate pain in certain C circumstances so our brain doesn't detect pain it makes pain like how interesting okay so although several potential risk factors have been identified you know we've mentioned that the causes of the onset of low back pain remain obscure And difficult um you know to and the

diagnosis difficult to make and many cases we talked about this um you know earlier um there was a systematic review done in 2009 and found strong evidence that Leisure Time sport or exercises sitting and prolonged standing are not associated with low back pain so that's interesting evidence for associations in Leisure Time activities who think of doing home repair gardening nursing tasks heavy physical work and working With one's trunk bent or in a Twisted position and low back pain is conflicting it's not clear if this actually causes low back pain or not okay psychosocial risk factors

for low back pain include stress distress anxiety depression cognitive dysfunction pain Behavior job dissatisfaction and mental stress at work and we're going to you know go into things like this a bit more detail okay so persistent pain is often correlated with depression with Fear with rumination and with worries about injury okay recent Studies have provided incontrovertible evidence that psychiatric disorders and other psychosocial factors can influence both the development of persistant pain conditions and the response to treatment okay so this does not mean that pain is all in one's head that's not what we're saying here

but it means that there is a strong link between experien pain and our current mental resilience so I'm Wondering if you've ever experienced that before I certainly have okay so I had a little um should injury I was having shoulder pain sometimes I'd feel fine then I would get stressed about something or I'd have an argument with my husband or you know something would go on and suddenly that day might the pain would feel worse because I wasn't feeling as mentally resilient yeah or I'd have a really bad night's sleep and the pain would be

worse that day yeah so There's a strong link here between these factors social factors have also been demonstrated to have an impact on persistent pain so these include return to work issues catastrophizing poor Role Models codependency Behavior inadequate coping mechanisms for things attitudes beliefs and expectations okay all have an impact on how you experience pain so what catastrophizing is it's when a person exhibits an exaggerated notion of negativity assuming the worst Outcomes it's basically making a mountain out of a mole hill okay that's a risk factor so persistent pain could be thought of as all

of life's stressors so think of the physical stresses in your life the social stresses the psychological stresses and the spiritual stresses exceeding our perceived ability to withstand or adapt to these okay to optimize outcomes the identification and treatment of associated psychosocial Issues is of Paramount Paramount importance so basically in the past we used to always think that low back pain was a phys IAL problem and realizing it's it's much bigger than that we need to take a holistic approach the the the best way to approach this is a multi- distri approach using What's called the

bioc psychosocial model and this a way of understanding how suffering disease and illness are affected by multiple levels of organization from the societal To the molecular so this is an example of a biopsychosocial model you know things that are going to come in to play impact how you experience low back pain could be your gender it could be um genetic vulnerability it could be be substance abuse but it could be Behavior it could be self-esteem issues it could be your education level it could be your socioeconomic status yeah it could be your temperament so we

have to look at things from a holistic perspective if we Want to help people to feel better you know particularly when it comes to um persistent pain and this is really helping people to have better experiences this holistic approach so it's important for us to realize that experienc some pain at different stage in their life as a normal part of Being Human it's a response to the pain that tends to be most significant so I'll give you an example the other week I was sat on the Sofa and I got quite sharp back pain now

if you if you'd rewind 10 years ago I might have thought oh god I've pulled a muscle or I've done something to my disc or there's something happening and I could have really kind of fed into that and I might have ended up with back pain for like that week whereas this around I went oh that's interesting my body's trying to tell me something like oh how am I sleeping at the moment am I feeling stressed am I doing enough yoga am I Moving enough you know maybe I need to prioritize seeing close friends and

having a bit more social engagement you know so the way you respond to pain is very very significant and then the pain went I didn't you know the pain disappeared and I was fine so often understanding and acknowledging pain can be desensitizing we got Britney Spears back again one more quiz so is this true or false Low back pain is the number one cause of disability in the world what do we think yeah yeah non-specific low back pain so low back pain with no known path of anatomical cause encompasses over what percent of all cases

what did we say here yeah up to 85% of cases the vast majority true or false Hern a diss account for only 4% of low back pain Cases yeah it's all good Lisa um can you list two psychosocial risk factors for low back pain that we've talked about the answer to three is is true yes 4% yeah thank you for this so personal relationships stress addiction depression sleep anxiety yeah you got it apology for The Barking I'm dog sitting too little chihuaha mixes are obviously gorgeous but they they'll fight Anything true or false our brain

doesn't detect pain it makes pain yeah it's true how [Music] interesting and then true or sorry um fill in the blank the longer a person experiences pain the what the correlation with tissue damage so is this stronger or weaker yeah it's weaker the longer you have pain the less likely it's coming from a physical Issue all right so let's look at her the discs because you know this is there's a lot of talk about this so our robust inter vertebra disc are interwoven with the with the vertebra and our supported by the many ligaments that

we've looked at the discs themselves can't actually slip out of place so a slip disc isn't a helpful term and also a rupture disc isn't helpful because it suggests trauma when often none has occurred so the technical term is a herniation that's When part of the disk pushes outwards Beyond its normal boundaries um and the medical professionals now have ways of kind of describing this depend on the extent okay so this is just one classification so dis protrusion is when the dis and the associated ligaments remain intact but form an out pouching that can that

could um press against a nerve a dis Extrusion is when the nucleus squeezes through a weakness or tear in the surrounding anus but the Soft material is still connected to the disk and then a disk um sequestration is when the nucleus not only squeezes out but it actually becomes kind of separated from the disk itself yeah so just to you know to give you you don't have to remember these so here's again normal experience here is a protrusion when this out pouching this is the Extrusion when it's really come you know separated out and this

is where part of it actually has now become separate so Just to give you an idea of what that's all about dis bulges and herniations are highly prevalent in painfree populations are not strongly predictive of future low back pain and correlate purly with levels of Pain and Disability based on robust science okay so this is really interesting stuff there was this Landmark study done in 2015 okay and it showed that in a group of 20 year olds who were not Experiencing backpain 30% of them had bulging invertible discs okay they also looked at a group

of 50-year-olds who were not experiencing back pain and they found that 60% of them had bulon death as you age the prevalence increases this is not associated with low backp these are all people that are paying free okay this tells us that these are normal age related changes that happen it's part of The Human Experience so let's take a look here these are the age categories In the 20s 30s 40s up to 80s and these are different types of findings so dis degeneration 37% of 20y olds have disc degeneration up to 96% in 80 year

olds these are people with no back pain this group yeah dis bulge 30% to 84% yeah um facet degeneration is the word we hear a lot isn't it degeneration 4% of 20 year olds and 83% of 80y olds no back pain so these finds are normal part of the aging process so this really changed the way We look at this we've already said that you know about 4% of low back pain cases are caused by Hern disc there's actually debate in the literature regarding nerve Supply to the interal disc and what role the dis could

play as a generator of back pain and then this was also a really interesting study again 2015 this was a systematic review so gold standard of medical of research 50% of patients with a um Lumber herniated disc had spontaneous resolution after Conservative treatment so this basically means Physical Therapy yeah so in this group they were they were monitored and after physical therapy 50% of patients had spontaneous resolution back to normal in terms of their Anatomy yeah they also reported that the patients that had um the more severe herniation had a greater chance of spontaneous um

regression okay so what it tells us there is the more severe the herniation the greater chance of spontaneous Resolution like that's wild so really we don't fully understand why discs behave the way they do um but if you have a discarnation hope for a big one because you've got a better chance of it going back into place spontaneously amazing it's a mystery okay so we're going to dive now into the concept of posture be open-minded here this this can be challenging because the idea of posture is so ingrained in our society we're going to look

at this from a um Scientific point of view from a research perspective okay essentially the idea of good posture is a social construct okay it's not backed by research so um it's basically been reported there different historians have said that the order to stand up straight has its roots in the development of the military drill in the 16th century and then by the end of the 18th century this posture had taken on the broader meaning as a way to mold a man into a soldier so this is where it All began so this idea of

be a man stand up tall okay and then posture became a way to transform a person into someone different a way to enforce discipline the concept of good posture began to be taught to the wealthy and fashionable in London and by the 19th century posture became a closely associated with Notions of Health and Wellness yeah the middle classes in particular spent their money on Self-care books which sold their Millions teaching them how to stand up streets you've seen pictures of people with stacks of books on their heads and things like that by the end of

the 1800s posture having broken out of the military into civilian life had become infused with the meaning not only of about discipline but also health illness mortality and Decay so if you had bad posture you you were maybe seen as less healthy if you this idea of good posture You' seen as healthy and maybe a better St status in the society uh it also start of become medicalized and still to this day this concept is highly ingrained in our culture Global posture correction Market is a multi-billion dollar industry ranging from ergonomic chairs and desks to

workshops for manual labors on the best posture for lifting to device like there's a thing called an upright that you can wear in your Lumber spine and it vibrates anytime you start To curve your spine just kind of wild you know so you know back in prehistoric times the whole posture was the hunch that's a joke obviously but you know just to say that posture changes with with the ages um you know and this has crept into yoga in a big way so how many times have you heard things like this this pose improves your

posture it's not something I say anymore you know cuz I just don't spend time thinking about posture in That way there also big focus on like lengthening or spy and yoga you know this things crep in so this is interesting this is this is robust science so there was this these two studies in 2010 they found that ergonomic interventions for workers advice for manual labors on the best posture for lifting they have not reduced work rated back pain so the millions and millions of dollars that have been spent in Industry trying to Improve the way

people sit and stand and move have not reduced work rated back pain okay if you have no choice but to sit or stand all day then stacking your joints will certainly help you conserve muscular energy but we also have to recognize that being in one fixed position for prolonged periods is not good for our body we have evolved to move we need to move as often as possible and you know prolonged sitting Is not good for us it's um associated with increased risk of cardiovascular disease so you know um breakups time um you know set

your alarm go for walks do your chair yoga sorry for the Barking in the background no single sitting or standing standing posture protects a person from back pain you can have what is seen as the perfect posture and you can experience back pain you can have sludged posture all day and not experience back pain okay so people with Both slumped and upright posture can experience back pain rather than how we set our standing the problem I believe that is the fact that as long as we're sitting standing we're not moving our body so move more

our posture can impact how we feel of course it can but it might be time to move away from the idea of an ideal posture and invest your time and energy on moving our bodies more throughout each day yeah so Britney's Back true or false disc bulges and herniations are highly prevalent in pain-free populations are and are not strongly predictive of future back pain yeah yeah what percent of patients can have spontaneous resolution of um hernia discs after just conservative treatment so no surgical treatment what was the percentage we said a lot yeah it was

50% well done Lisa yeah Great true or false ergonomic interventions for workers and advice for manual workers on best posture for lifting um have reduced work rated back paying all these millions of dollars but have they reduced it no they haven't based on this pretty robust research really fascinating stuff um high amounts of setting time is associated with increased risk of what kind of disease what was the disease I Mentioned yeah cardiovascular yeah at least the heart disease essentially yeah all right okay here's another one again I'm not just trying to trade you this I

I just really want to present the latest research um let's talk about core stability okay be open to what I'm sharing with you so the concept of core stability has only been around since the late 90s it's everywhere isn't it it's Largely derived from studies that did demonstrate a change in the onset timing of the trunk muscles and back injury and a case of low back pain so you know there's some research that kind of started this whole idea of core stability okay these findings combined with General beliefs about the importance of abdominal muscles for

strong back and influence from from palates in the '90s and promoted several assumptions prevalent in um core Stability training so these are all assumptions certain muscles are more important for stabilization of the spine prly the transverses abdominis okay weak abdominal muscles lead to back pain that's assumption strengthening abdominal trunk muscles can reduce back pain there is a unique group of core muscles working independently of other trunk muscles a strong core will prevent injury okay there's a relationship between stability and back pain as a Consequence of these assumptions a whole industry grew out of these studies

with gyms and Clinics worldwide teaching the Tommy Tuck and trunk bracing exercise to athletes for prevention of injury and to patients for a cure of low back pain okay and again a multi-trillion dollar industry has been ated out of this so core stability exercise as prevention of backpain question mark so in one study this is in the '90s when this was taken off um there were asymptomatic patients So four 402 patients with no back pain were given either education or back Education Plus abdominal strengthening exercises and then they were followed over a period of time

okay they were followed over a year and the number of backp episodes were recorded there were no differences between the groups so whether you were just given education like this webinar or you're given Education Plus abdominal strengthening for a year there's no difference between The number of back pain episodes okay um there was a curious aspect to the study which is important to the the strength issue here the stud was CED with asymptomatic patients who were identified as having weak abdominal muscles so it is important it is possible to have weak abdominal muscles and not

have back pain yeah so 400 individuals with weak abdominal muscles and no back pain there was a large scale study that also Looked at the influence of core strengthening um in Collegiate athletes okay so in this study too there was no significant advantage of core strengthening in reducing low back pain occurrence and this this really interesting study um or paper that will break this all down for you I will include this in the references the myth of course stability it's a really fascinating read okay so um it tells us that weak trunk muscles weak abdominals

And imbalances between trunk muscles groups are not pathological they're just a normal part of human variation um the division of the trunk into the core and Global muscle system is reductionist okay it doesn't actually help weak or dysfunctional abdominal muscles will not lead to back pain there's no science that backs that up um tensing the trunk muscles is unlikely to provide any protection against back pain remember we have all these deeper ligaments and Muscles that are already providing the stability that we need you know that we looked at earlier um core stability exercis are no

more efficient than and will not prevent injury more than any other form of exercise okay um cor stability exercis are no better than other forms of exercise in reducing chronic low back pain and any therapeutic influence is related to exercise effects rather than the specific um exercises that you're Doing the fact that you're being more physically active is is why you might see an improvement rather than the fact that you're strengthening your core muscles yeah and a really interesting fact that we mentioned earlier again is that you know many of us or some of us

do not have a transverse abdominus but it doesn't mean that you're going to end up with back pain okay so really interesting stuff and a similar vein what about weak glutes what about short Hip flexors all these things that we say that can cause back pain it's just way too reductionist yeah and again yeah you can do a whole sequence of glute strengthening and this can maybe help with you can then end up with less back pain but it's the fact that you're being more physically active that's probably the thing rather than the fact that

you're actually strengthening the glutes yeah you know saying that a weak glutes causes back pain it's it's like imagine The body's like a machine which is not and pain is just so much more complicated than this if only we could just strengthen our glutes and have no back pain that would be wonderful but things are way more complicated than that there's no such thing as a quick fix or a hack if you want to feel the best you can feel in your body every day you have to show up for yourself every day you have

to prioritize your sleep you have to have stress coping Mechanisms you have to be physically active you know you have to um you know do your yoga do some restorative yoga like you you know all the things that you know make you feel good you have to show up yourself every day there's no quick fix or hack here it keep showing up for yourself so what do Britney got to say for herself so true or false there is clear there a there is a clear Universal definition of the core we didn't really Touch on this

is there is there one definition of the core or there multiple yeah false there are loads of different definitions there's no agreement on this um true or false weak or dysfunctional abdominal muscles will not lead to back pain what do we think yeah based on This research that's true no I I love doing core exercise it makes me feel centered it makes me feel strong I think it's just as important as as strengthening any other part of the body But I'm not under the illusion that's going to prevent me from getting back pain true or

false core stability exercises are no more effective than and will not prevent inj injury more than any other form of exercise yeah that's true so be active but again you know don't think you have to just be doing one form of activity to help your spine so the power of language the most important thing we can do to improve our Back pain or help others begins with language and mindset I started the workshop off with this I'm going to reiterated yeah so many unhelpful beliefs about back pain are common amongst the general population the media

yoga teachers and even medical professionals unhelpful beliefs are associated with greater levels of pain disability work abs CM medication use and Healthcare seeking okay unhelpful beliefs can trigger what is known as the Nobo effect so most of you are probably familiar with the placebo effect what about the nobo effect well the placebo effect demonstrates the tremendous power of expectation so if you um if I was to give you a tablet and tell you oh this is the latest high blood pressure medication and I give you it every day even though it's just a sugar tablet

I would measure your blood pressure the end of the week in your blood pressure would have lowered because you had a Positive expectation okay but what if an expectation is one of harm the power of expectation can go either way favorably or unfavorably okay so the no sibo effect describes the phenomenon of experiencing an unfavorable event from an otherwise harmless event unfavorable effect from otherwise harmless event so imagine that I was giving this tablet every day I told you it was cyanide but it was just sugar you would end up having symptoms Of being poisoned

by the end of the week okay so it goes both ways the noo effect occurs not just with the ingesting of an inert P it can also occur with a simple verbal suggestion like keep your knee above your ankle to protect your knee joint or engage your core to protect your lower back someone can be an oppos and like oh my God I forgot to engage they could end up having back pain as a result of that in that moment yeah so I would say never Use the word protect it's a a trigger here's the

Nobu effect so if people are told that something will hurt they're more likely to experience pain when people with pain have a scan and normal age related changes are reported as degeneration or abnormalities those people recover more slowly regardless of the nature or the cause of their original problem language is so important fear-based beliefs set people up with negative expectations and this Has been linked to poorer outcomes and greater pain fear avoidance beliefs have been shown to be prognostic for um poor outcome in patients with low back pain yeah so people that are go no

I can't I can't Flex my skin I can't do this activity if they're if they're avoiding things then you know they're going to have a poor outcome consider whether you've heard any of the following cues in a yoga class I've just touched on this engage Your core to protect your back engaging your glutes and bridge pose compresses the lower back the secr iliac um joint is a very vulnerable joint you know this is this is all going to trigger the no sio effect yeah so while these cues are surely well intentioned they suggest that our

backs are fragile and can elicit the nobo effect our bodies are not just robust they are antifragile so our bodies respond Positively to the demands placed upon them obviously this has to be within reason and has to be Progressive but the more demands we place in our body the stronger it becomes so we're antifragile though any tissue of the body can of course be subject to Injured disease our bodies respond positively to change so do you want to share a message that our bodies are delicate and prone to wear and tear or do you want

to share an empowering message that throughout Our lives our bodies maintain the ability to adapt in positive ways and know what I want to do the latter is not just more important it's also more accurate in terms of the science we have available about the human body okay so think of using language that is empowering rather than saying stop if anything hurts consider saying just do what you can hopefully some movement will help that's more Encouraging I believe you would be correct in saying that movement and exercise are some of the best things we can

do for our body and science supports that claim how exciting so let's dive into this in a second you know more than 75% of people have not heard heard of or don't believe in the nobo effect so sharing this information with others can help um therefore awareness recognition of the nio effect is a good first step while Unhelpful beliefs can worsen low back pain the opposite is also true a positive mindset around low back pain is associated with lower levels of pain disability and health seeking healthare seeking so um once red flags and serious pathology

is excluded evidence supports the following low back pain is not serious life is not a serious life-threatening condition in most cases obviously we're excluding those cases That that are serious um most episodes of low back pain improve and it does not get worse with age there's a belief that it's going to get worse with age it doesn't have to a negative mindset fear avoidance behavior negative recovery expectations and poor pain coping behaviors are strongly associated with persistent pain more so than tissue damage scans do not determine prognosis of the current episode of low back pain

nor the likelihood of future low back Pain disability and they do not improve clinical outcomes so we're scanning people less in the medical community which is a good thing you know obviously if there's a red flag you'll get scanned um yeah and here we are you know so really unless the red flag you shouldn't be scanned for low back pain it's just not helpful it can be unhelpful um spine posture during sitting standing and lifting does not predict low back pain or its persistence A weak core does not cause low back pain and some people

with low back pain tend to actually overuse their core muscles where it's good to keep the trunk muscle strong it has also helped to relax them when they're not needed spine movement and loading are safe and build structure resilience when done gradually and progressively pain flareups are more related to changes in activity stress and mood rather than structural damage that's important One effective care for low back pain includes patient centered education that Fosters a positive mindset and coaching people to optimize their physical and mental health by engaging in physical activities and exercise and social activities

developing healthy sleep habits and achieving maintaining um you know ideal body weight and remaining employed and active while back pain can be frustrating at times disabl it is Helpful to remember that 90% up to 90% of low back pain cases are self-limiting and resolved within six weeks many factors affect back pain including our own perceptions of the pain itself knowing that our language can affect pain through the noo effect we're well advised to be aware of how we use our words and as with everything else in the body one of the best treatments we can

pursue for back pain is just what our yoga practice provides Movement so let's do a quick self test so the most important thing we can do to improve our back pain or help other s begins with what what were the two things I said that really can help language and mindset well done Barbara true or false unhelpful beliefs about low back pain are not associated with greater levels of pain disability work absenteeism Etc is that true or is it false that's actually false yeah they Are Associated when people um with pain have a scan and

normal age Rel changes are reported as degeneration or abnormalities I'm sure we've all been there those people recover more what regardless of the nature or cause of their original problem do they recover more slowly or more quickly they recover more slowly language has a big impact on our experience true or false fear avoidance Beliefs have been sh to be progn prognostic for poor outcome in patients with low back pain as fear voidance a factor it is done true or false a positive mindset around low back pain is associated with lower levels of pain disability and

healthc Care seeking correct well done everyone true or false diagnostic imaging test should not be used if there are no clear indications of a serious pathology correct we're moving away away From scanning everyone that has little back pains just not helpful all right so let's now dive into some physical activity guidelines as we begin to move towards the end of the content so to reduce the probability of disability individuals with low back pain should stay active by continuing ordinary activity within pain limits avoiding bad rest return to work as soon as possible following an acute

bite of low back pain Early Access within 3 weeks to physical Therapy results in dramatic red uctions in opioid use injections and surgery as well as decreased disability so get help you know if you're if you're experiencing low back pain you know persistently go get some help get some physical therapy it's going to really help you in the future if disabling pain continues Beyond 6 weeks you really need a m multidisiplinary team to you know to look at things many individuals with low back pain have fear anxiety or Misinformation regarding the low back pain exacerbating

a a persistent pain state so this is why getting upto-date information so important a combination of therapeutic and aerobic exercise in conjunction with pain education improves individual attitudes outcomes perceptions and pain thresholds so that's exciting best evidence for treating low back pain indicates physical activity as a key component in managing the Condition so this is something that we have control over how Physically Active we are individuals with low back pain who are fearful of pain or reinjury often misinterpret any aggravation of symptoms as a worsening of their spinal condition and hold the mistaken belief that

pain necessarily implies tissue damage it does not in contrast those with low back pain who persist and physical activity may not allow injur tissues the time it's needed to heal so This is all about the Goldilocks principle it's find in The Sweet Spot it's up to you as an individual to do that yeah you can be guided but you have to find it you know so you have to um you know take time to think well okay I'm experiencing a little bit more back pain today what what what did I do was I too active

that I push myself too much in yoga yesterday maybe I need to reduce the weight at the gym a little bit for a moment and then see how that goes so Play around with it to find The Sweet Spot you want to find the amount of activity that is not too small not too big just right just like the porridge um we've mentioned you know we've mentioned parts this but there are no clear there's no clear relationship actually between your amount of flexibility and the lower back pain which is interesting um it may be best

to avoid exercise in the first few days immediately following an acute or severe Episode of low back pain as to not exacerbate symptoms but you should not um have bad rest so it it means you're not going to be um you're not going to do specific exercise but stay active do your household tasks move around don't stand bad both progress Rive aerobic training and progressive resistance training have been shown to be equally effective at decreasing pain intensity and individuals with chronic low back pain Most favorable outcomes with um an individualized approach that addresses psychological distress

fear avoidance beliefs selfefficacy and controlling pain and coping mechanisms so really you know it is we these are guidelines but really it's about looking at an individual person and seeing what they need so I'm going to share a link to this you know with with later this is from the American College of sports medicine they cre this really great Infographic um All About back pain so in general you know if there are no red flags um recommendations for exercise treatment for low backpain they're consistent for healthy adults you know so like it's you know this

guide just really great you know keep it simple sit less move more walk to the mailbox take the stairs you know talk to your healthc care provider make a plan maybe um exercise with the friend you know it's it's it's kind of simple stuff but but Really really helpful um you know lots of tips and tricks in this infographic that I'll share with you um you know if you suffer from depression anxiety stress or insomnia get help for those that can also improve your pain you know so lots of different little tips and tricks that

you can explore in your own time gives you you know a guide for you know how Physically Active you want to be you want to do about um an hour sorry two and a half hours of moderate um Exercise a week break it break it down you know so that could be know building up slowly to maybe 30 to 60 minutes a day so we're going to you know build that up slowly there's a little bit of about strength training and high to approach it you know again just be a progressive approach so you can

take a look at that in your own time and then you know it's promoting some flexibility training a little bit Of posture awareness also mentioning yoga Pilates Tai Chi you know which is great um you know just some special considerations you know individual response to back pain symptoms can be improved by providing reassurance encouraging activity and promoting early referral to physical therapy certain exercise or positions May aggravate symptoms so be willing to adapt you know for yourself or for your yoga students Obviously um limits should be placed on any activity or exercise that causes the

spread of symptoms so if you're suddenly having low back p and then n spreading down your leg then you you know you really want to look at that um flexibility exercise are genuinely encouraged as part of an overall exercise program hip and lower limb flexibility should be um promoted so this interesting exercises such as yoga and Pates have shown to be Effective interventions for low back pain however the research is not clear on whether any single intervention is superior to another therefore the choice of exercise should fundamentally be driven by client preference and practitioner expertise

so the great thing is you know if if yoga is your thing and you love yoga great keep doing it it's going to help you here yeah but if you actually prefer to cycle or to jog then do that don't feel like you Have to do a certain thing to help yourself just be more active and then you know there's a little bit of research here about mindfulness um you know basically saying that you know it's lowquality evidence but there is um has been found to be an association with a small decrease in pain when

you know when having a regular meditation practice which is which is nice to know um there's some research that looks specifically at yoga and low back pain Um there's strong evidence for short-term Effectiveness for yoga and moderate evidence for long-term Effectiveness for low back pain so that's great again it doesn't mean that yoga is better than any other form of physical activity but you know um you know if yoga is your favorite form of activity great keep doing it and if not it's all good do something else so true or false to reduce the probability

of disability Individuals with low back pain should stay active by continuing ordinary activity within pain limits avoiding bad rest and returning to work as as quickly as possible yeah TR it's the best approach current research shows that following an acute bite of low back pain Early Access to physical therapy results in dramatic what and the need for opioid use injection surgery and is it an increase or a decrease yeah well done decrease that's Exciting true or false individuals with low back pain who are fearful of pain or reinjury often misinterpret any aggravation of symptoms as

a worsening of their spinal condition thinking this further tissue damage it's true and it's highly unlikely that that's the case it's very normal to have a little bit of aggravation particularly when you're being Physically Active we need to reassure people with that um both Progressive what training and what training so what were the two different types of training have been shown to be equally effective but decreasing pain what were the two types great yeah aerobic and strength or resistance training fantastic true or false flexibility exercise are generally not encouraged as part of an overall exercise

program for low back pain what do we think that's false yeah Flex is good yoga is going to Really help with that exercis such as yoga and plates have show have shown to be effective interventions however the research is not clear on whether one is superior to the other what do we think that's true so if platies is your jam keep doing it you know don't feel like you have to be doing one specific thing so as we begin to wrap up some general advice for yoga teachers when you have student with low back pain

be encouraging I know sometimes it can be a Little bit scary I'm hoping that this information has empowered you adopt a positive encouraging approach be aware of the language you use when someone shares medical information with you imagine someone comes say I have I have really bad low back you're like oh my god wow it sounds awful I can't believe you even made it to class so go thank you for sharing this with me how do you think I can support you today you know so just be mindful of not feeding into Some narrative rather

than saying stop if anything hurts what about saying just do what you can do today hopefully some movement will help so instead of someone always looking out for the pain do what you can do hopefully some movement will help yeah motion is lotion movement is medicine you know some phrases I like to use feeling pain during a yoga class doesn't mean that tissue damage is Happening now obviously we're not going to be pushing people into pain in a yoga class that's not the right setting there is actually some interesting research and a physical therapy setting

that when you feel pain during one of those sessions you're actually more quickly to recover but it doesn't mean that we're going to do that in a yoga setting but feeling a little bit of pain or discomfort it doesn't mean that tissue damage is actually happening avoid Fear-based language do not use the word protect you can say if you want to engage your core don't say it's to protect your low back don't predict the future so don't tell someone what kind of experience they're going to have you're going to set up a negative expectation so

I used to I'm going to be honest with you if I had a student 10 years ago with a hernia disc I would say okay you're going to want to avoid twisting and flexing your Spine don't do that because you might have two two people side by side who have the same degree of herniation at the same level one of them feels relief when they twist one of them feels discomfort and will need some options so just don't predict the future get really confident modifying poses um if you check out my social media you'll see

that I share reals and photos of loads of creative ways to explore back bands to explore Warrior 2 To explore chaturanga all these things yeah so get really confident get confident in your own practice doing different options of poses and then you'll become more confident offering them to people these these are all examples of backbands yeah they're all great practice as I said you know get this into your own body the modifications the options don't just focus your attention on the lower back if you have a student with low back pain Think of all the

other things they can do all the other parts of the body that are not experiencing pain so focus on what your students can do rather than on their limitations okay some additional really helpful resources is great guy called Greg Leman you'll get you know obviously in the presentation PDF you can click on this link it's a whole workbook on pain science very generous of him and then this is the link that you'll get which shares you this really Cool infographic that I that did a little Snippets you know um from the American College of sports

medicine I think it was yeah so that that's a link for you we've covered a lot of information um reflect on the content that we've covered today today and write down five things that you really want to take away with you share them with someone else in your life and you will be able to hold on well to that Information yeah um you'll receive a copy of the slideshow all the references reach out to me if you need anything here's my website here is my email address if you want a certificate for today anything like

that just reach out it's all good um and if you want to study with me more I offered this really amazing um on demand um Anatomy course you get lifetime access is 30 hours you can do it as many times you want you can also Interact with me during live q&as every 5 weeks and as a b Yogi member you can get 15% discount using the code B yogi5 we're going to email you links and all that kind of stuff um you know thank you so much for joining me um because you've signed up for

today you are going to receive my newsletter I send it out once a week it's got great information you can unsubscribe at any point if that information doesn't resonate with you but you'll hear from me more for sure so Thank you so much it was such a pleasure to do that and thank you for um be all being so um patient with me um with that technical fault at start awesome Andrew I'm just gonna kind of hop on we do have a couple of questions um I also encourage um if anyone else has any further

questions feel free to drop it in the chat or the Q&A feature um at the bottom of the screen so starting out um from Carol Brown we do have a question what are Your thoughts on Lauren Fishman's early work um Lauren Fishman is Lauren Fishman the person that did the research on yoga and osteoporosis I'm wondering H maybe they can maybe they can someone could tell me yeah yeah so I I don't know about I don't know necess about his early work what I will say is there's a lot of um talk out there that

that yoga can help um reverse bone menal density loss in case of osteoporosis and unfortunately it's this is not correct Yoga is just not Progressive enough to bring about meaningful change to your bones now it can be a great first step if you're inactive But ultimately you need high impact and resistance training that's done ideally under a supervised condition so you know I run um separate workshops on aser proess we critique the work that's done by Lauren Fishman and um also I believe that I I did a short one with Bogi actually last year so

that that will still be Available won't it Shannon people can watch the replay so you know yeah yeah we have all of our webinars on our YouTube so um it is uploaded there as well great so there like an hour presentation on that and we cover all the information so definitely check that out yeah awesome perfect um we have a question from Brooke is there a relationship between abdominal strength and balance or is this a Moma as Well um yeah balance is more complicated than that a lot of balance comes from the ears you know

but basically yeah look of course um you know when I have done intensive core work I find that I'm better than when I go ice skating I'm not going to fall over as much you know so yes there definitely so look core work is important um in this context just don't think it's going to reduce the the prevalence of low back pain but it definitely has Other great benefits to and I love doing it myself so hopefully that helped Maria asks what are your thoughts on twist with dis issues do you agree with avoidance yeah

so hopefully you know this has been covered there at the end I I don't think we need to avoid that at all I think there there there's something for everyone you know we we can um I literally did a post on in last week on uh a reel on Different Twist variations and there there's Always something for someone so just be be creative um even if it's twisting 10 degrees keep keep moving the spine we don't want to avoid spine use it or lose it yeah awesome we have a question from Barbara how do you

reconcile your findings with the yoga Field's desire to show benefits of yoga through many of the claims you deel yeah it's a tricky one look I've you know written a whole book on this it's Called the physiology of yoga and it's really my mission just to share correct evidence-based information it's not it's not expert opinion it's not my opinion on stuff it's everything that's backed up with medical research so yeah it's challenging but I think there is a movement over time where people want to um have a little bit more evidence and are questioning things

say more which I think is really important awesome question from Diane What is the difference between pain threshold and tolerance and does moving more increase either of those pain threshold and pain tolerance I guess there imagine they're very similar and yeah I think I think um moving might help I think the way we think about the body so if you know remember going back to the anatomy we looked at the start if you can visualize those ligaments and those muscles and and no longer think of this part of the body as being fragile That's the

thing that's actually going to change your pain threshold yeah the language you use to describe your body that you know the these are the things that are going to that going to Ultimate change that I believe yeah so that's quite exciting awesome perfect I don't see any other questions at this time U Maria said thank you for your response on twist I have enjoyed your presentation awesome super happy about that yeah just Thanks everyone for being so open to hearing it you know and I know there are things that can feel challenging but you know

have keep an open mind and it doesn't mean that you know I have to leave and take everything that I've said and like change your whole perspective but just be really open to questioning your pre-existing beliefs um follow you know follow me on social media I I post stuff um I think you'll really enjoy my regular newsletters they're full of Really great information often share excerpts from my books and things like that and um yeah it's been really great I'm going to make a mental note to provide a little bit of information on the secret

joint what I'll do actually is um Shannon I when I'm sending you like the PDF of the presentation the references I also share a link to a previous newsletter with that was all about the secreta joint and I think that will be helpful for people perfect Lisa Says have I heard of Dr Sno healing back pain I have heard of him I haven't like looked at any of his materials in depth but I definitely have heard of him so I'll look up I'll look at look at him in more detail Lisa so thanks for that

um yeah and thanks Shannon so much for hosting me it's been such a pleasure yes thank you so much Andrew for coming on again um thank you to everyone who uh registered and there will be an email going out tonight with The recording with all the information with the um discount as well and the link for our biogi members so thank you so much again thank you Andrew and I hope everyone has a fun and safe holiday weekend yeah happy fourth everyone enjoy the rest of week and yeah and you'll hear from both shann and

I in the next few days yes thank you so much bye- bye bye everyone