This article is an excerpt from my enormous low back pain tutorial.
Meditation and yoga are appealing activities for a lot of people (and a lot of reasons), and they do have many potential benefits for anyone who chooses to get serious about them. For example, a diligent meditation practice can improve sleep quality, which in turn can help back pain, because sleep deprivation is one of the sneakiest factors in all kinds of chronic pain. But it’s not for everyone.
The reputation and popularity of yoga and meditation is immense, almost oppressive, eclipsing other options in many people’s minds. People feel that they “should” try them in order to reduce stress and contribute to a healing process, and have trouble thinking of any other way of responding to pain and stress.1 They actually feel guilty for not trying them or for not liking them. Tyranny! Yoga and meditation have their uses, and are probably good for our general health,2 but no one should be feeling guilty about passing on them, and there are other options.
As popular as yoga and meditation are in North America today, they are still not mainstream.3 (Indeed, they are part of the “popularity myth” of alternative health care.4) Most of my massage clients over the years had only dabbled in them, at best. Nor did they ever report any success more significant than “taking the edge off” their stress or their aches and pains.
When corporations start prescribing yoga and meditation
This is a truly perfect example of what I mean be the “tyranny” of yoga, so good that I knew the second I saw it5 that it would have to be prominently added to this article (which hasn’t change much in years):
EVERY COMPANY: We’d like to promote mental health in the workplace.
EMPLOYEES: How about hiring more people so we feel less pressured? And maybe increase our pay a bit so we can keep up with the spiraling cost of living, so we’re not so stressed out?
EVERY COMPANY: No, not like that. Try yoga and meditation.
Hilarious and all-too-true. Don’t get me wrong, yoga can be great, but all normal people know it’s an irritating and inadequate as a default prescription for stress. Speaking of normal people…
Many people are poor candidates for yoga and meditation
If you’ve never been interested in yoga or meditation before, or never really tried it, it may not be a great idea to try to take them up just because you’ve got a new pain problem. Someone with low back pain who has already got some experience with yoga and/or meditating might find it more useful.
Many productive, energetic people find it difficult — almost alien — to invest in subtle or indirect methods of self-improvement, and find the quiet challenges of meditation and mindfulness particularly exasperating. Many are allergic to the many bogus claims associated with it (like reprogramming your DNA? sheesh). Mindfulness is particularly a mess, with scientific excitement about its potential reaching well beyond the evidence.6 Even if they can get past the flaky stuff and like the idea, they may still have a sort of personality conflict with the slow pace and calmness required. If so, the learning curve will feel especially steep. It will take anyone some time and dedication to make real progress. Trying to climb that curve quickly when you’re not sure it’s even a good fit for you, while also coping with a pain problem or overwhelmed by an acute episode of life stress — the very times when people are most likely to “try yoga” — is usually not a practical solution.
Another large group of people who aren’t suited to yoga and meditation: the ones who never liked the idea to begin with! You know who you are, and you’re not alone. Plenty of you suspect that all “that flaky stuff” is a cure that’s worse than the disease. You are more likely to be successful reducing stress the standard “Western” way, by “blowing off steam” with exercise! Which can be a great idea, except that blowing off steam is often not an option if you are struggling with a healing process. In fact, one the biggest stresses in your life may be the loss of exercise, which was the only stress-management strategy you took seriously.
When I was a massage therapist, many of my clients clearly identified this exasperating catch-twenty-two: they noticed that stress aggravated their pain (or perhaps even triggered it in the first place) … yet they had to solve the problem before they could exercise again to reduce the stress!
That’s frustrating. Stressful, even!
Please do consider the option of studying yoga and/or meditation. They are worthwhile pursuits, and they definitely have some potential to reduce stress, back pain, and other pain, and offer you a host of other personal development benefits. But rest assured that it’s just not that big a deal. They are hardly slam dunk cures.7 They are not the only options or the best options. Indeed, as of some new research in 20058 and 2011,9 it is now more or less proven that yoga is generally no better for low back pain than standard exercise and stretching classes — quite a blow to yoga pride. Yoga is either entirely ineffective for low back pain, or so unimpressive that it may be disregarded without worrying that you’re missing out on much.
In fact, there are even risks…
Yoga dangers? Really?
Not only is yoga not exactly required, people do actually get hurt in yoga classes. Which is hardly surprising for an industry so polluted with pseudoscience and myths. True story.
I have seen and heard about a great many (mostly minor) yoga injuries in my career. And people who go into yoga classes with a problem probably get hurt more often, and may have more faith in the safety of the class than it deserves — many yoga instructors portray themselves as health professionals competent to do yoga “for” conditions like low back pain, but this is a nonsense. Safe and competent care for low back pain is simply way beyond the competence of yoga instructors.
For a while in early 2012, the New York Times most-shared article was a “yoga bashing” article by William Broad, How Yoga Can Wreck Your Body10 — an excerpt from a forthcoming book, describing potentially serious yoga hazards, such as stroke. Broad raises a legitimate concern about a gap between a popular belief (“most yoga is safe and beneficial”) and the more likely reality: some fairly common postures and practices are almost certainly a little dangerous, and there may well not be enough yoga-specific benefits to justify even small risks. (Plus, the rationale for quite a lot of more extreme yoga is just total bollocks, and certainly deserves to be challenged on general principles.)
I don’t think Broad’s piece is particularly “sensationalistic” (as many yoga apologists11 have asserted, of course), although I do acknowledge a couple serious flaws. It’s a given that any athletic activity has both rewards and risks. The problem is that any risks are a really rotten price to pay for many of the more ridiculous motives for bothering with yoga in the first place.
If you’re not too sure you even like the idea of yoga in the first place, the mild but real safety issues are well worth considering. Plus, you could crush your cat! Be careful …
Meditation may even be a bad idea — potentially harmful — for people with some psychological problems.12 Not hard to understand why someone with obsessive-compulsive disorder, for instance, might have trouble with it.
For the average healthy person, though, admittedly meditation is much safer than playing in traffic or •shudder• running with scissors. It’s probably safer than taking a shower.
However, it’s still not without its hazards. At least some meditators will succumb to an unpleasant psychological experience known as a “dark night,” which is like a bad drug trip: an emotional, existential crisis brought on by the mental rigours of seeking an altered state of consciousness. Blogger Gianna Kali explains that this “can be misconstrued as psychiatric issues,” which can lead to some tragic outcomes.
It’s an unlikely fate for the dabbler, of course, and I do not wish to sensationalize a trivial risk. Tord Helsingeng, a Norwegian massage therapist, points out that
‘dark nights’ are relatively rare even for practitioners who are ambitious with their practice, going to silent retreats with 8+ hours of meditation every day for many days or even months etc. If someone has come to such a stage that this would occur — which is essentially an integration problem with the no-self — they would have already managed a whole tool-box of techniques to deal with chronic pain.
“This sort of thing generally happens with more serious pursuit,” Kali concedes, “but the fact is one often doesn't know who might become serious.” Her article on the risks of meditation is worth a look. It makes for an interesting contrast with the widespread belief that meditation is totally safe and the only real option for trying to learn to cope with stress.
And then of course there’s the much more prosaic hazard of just wasting your time and money.
There are lots of different types of meditation. Don’t trust anyone who says that their special brand has been proven scientifically to be better for your health than the other flavors. Watch your wallet.
~ Robert M Sapolsky, Why Zebras Don’t Get Ulcers, 2004 p. 402
Yoga and meditation alternatives abound
I think it is important for people to realize that movement and a bit of quiet time are what everyone needs to feel their best. Often yoga and meditation dogma gets in the way of just basic healthy lifestyle concepts.
— Byron Selorme, Shavasana Yoga Centre, Ontario
Motion is lotion! “Mobilizations” are a nice alternative to yoga for many people. And they certainly don’t come with all the philosophical, spiritual and cultural baggage of yoga. See Mobilize!
For some people, a simple stretching program avoids that whole “cult of yoga” atmosphere, but can feel just as nice and may well have essentially the same benefits, whatever they may be. Consider: a 2011 study showed that a program of static stretching alone — just pulling on muscles — had a nice clear benefit for heart rate regulation, a common way of measuring fitness.13 Bodies probably need constant sensory feedback for optimum function — again, “motion is lotion” — and this evidence is probably a nice demonstration of that principle.
And some people find that strong breathing exercises like bioenergetic breathing are a great way to more literally and directly “blow off steam”: see The Art of Bioenergetic Breathing. There are some excellent methods of reducing anxiety: see Anxiety & Chronic Pain.
Or breathe slowly with extended exhalations. This might be the only active ingredient in meditation: spending more time exhaling than inhaling is measurably more relaxing than the reverse. No new age claptrap here, just leveraging well-known biology:
Whenever you inhale, you turn on the sympathetic nervous system slightly, minutely speeding up your heart. And when you exhale, the parasympathetic half turns on, activating your vagus nerve in order to slow things down (this is why many forms of meditation are built around extended exhalations).
~ Robert M Sapolsky, Why Zebras Don’t Get Ulcers, 2004, p. 48.
As nice as massage is, it’s only two clearly proven benefits are: reducing depression, and reducing anxiety.14
Curing insomnia is one of the most obvious methods of reducing stress: see The Insomnia Guide There is also a lot to be said for pursuing personal growth: see Pain Relief from Personal Growth. If you have low back pain, there are many other options to consider. In fact, I wrote a whole book about them. There’s also quite a lot more information in the book about the science of yoga as a treatment for low back pain. See:
This image is a recreation of a popular “viral” image from a wellness guru, widely and uncritically shared on social media in 2015. Obviously there’s something to be said for the style of advice given in the image, and by no means am I saying that doctors shouldn’t discuss these options with their patients. However, my colleague Alice Sanvito saw the same problem I did: it’s a great example of “shoulding” on someone who may well have serious socioeconomic challenges that make such advice tone deaf and trite at best, the tyranny of wholesome expectations, or downright offensive at worst (sexist, racist). Here’s Alice’s full, brilliant rant about it:
You know, some people see this and think oh, yeah, this is how [the doctor/patient relationship] should be. I look at this and I see an older, patronizing white male authority figure dispensing a prescription for failure to a young woman whose life is probably so different from his own that he can barely imagine her problems.
What are the circumstances of her life? Does he know? I thought homeopaths [holistic doctors] were supposed to treat the source of the problem, not the symptoms.
What if the real problem is that she’s a divorced single parent in a crummy job that barely pays her basic expenses and all that entails? Like, how about a prescription for decent wages, working conditions, benefits, childcare, healthcare, public transportation?
Does the good doctor have a prescription for the gender gap in wages? Which is even higher for physicians, where women earn, on average, 62% of their male counterparts, significantly less than the 77% of men’s wages they tend to average overall.
I’m sorry, but this comes across as so simplistic and patronizing and it just makes me cranky. Here’s what many real women might say:
Doctor, I don’t feel well and I’m not sure why. I hate my job as a checker at Walgreens. I have to stand in one place all day. My feet and my back are killing me, they won’t let me sit on a stool. They keep me at just under 35 hours a week so they don’t have to pay benefits. I don’t get a regular lunch break and I have to listen to that awful canned music they play all day, plus deal with customers who don’t know what they want and take it out on me. They change my schedule from week to week so I can’t get another part-time job. My kids’ father isn’t reliable about picking them up from school. My boyfriend refuses to use condoms. I don’t want to go back on hormonal birth control, I didn’t like the way it made me feel when I did, but I really don’t want to get pregnant again.
I suppose I could get up extra early and meditate in the morning before I have to get the kids up, make their breakfast, get them to school, before I start my shift at the drug store. Yeah, I guess I could try to get in some exercise on my half hour lunch break or after work, but I’m so tired from being on my feet all day and then I need to get the kids, get to the grocery store, make dinner. Yeah, I’m trying to make from scratch and avoid the prepared stuff but I don’t know, that organic stuff is awfully expensive. The kids are complaining cuz I won’t let them have Fruit Loops for breakfast like the other kds. Shoot, after dinner, I’ve got to stay on them to get their homework done while I”m cleaning up from dinner and doing laundry and trying to get the bills paid. I just found out my rent is going up and the gas bill was really high the last month, though if I don’t pay the whole thing, they can’t turn me off yet because it’s still winter.
I suppose after I get the kids bathed and read them a story and finally get them off to sleep, I could try meditating then, if I can stay awake, but when I do, I keep thinking about when I’m going to get the car to the mechanic because those brakes are getting a little soft and I’m worried about that. Yeah, I guess I shouldn’t worry about things I can’t control.
I guess I could try to get outside more on my days off - I gotta work most weekends - but I’m so tired, I don’t get enough sleep most of the time, and if I have a day off during the week, I use it to run errands because the kids are in school and I can get some things done.
Oh, by the way, my mom may be moving in with us. She had a heart attack and isn’t dong too well. She really shouldn’t be living alone.
Yeah, you’re right, I should meditate and eat organic food and exercise outside, I’ll work on that. And I gotta stop worrying about things I can’t control. You’re right.
You know anyone who’s hiring? Full time? With benefits?
Wait a minute . . . why am I spending money to see a holistic doctor who’s telling me something I already know and recommending useless homeopathic remedies and herbal supplements? I can’t afford to be wasting money on placebo medicine!
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About Paul Ingraham
I am a science writer in Vancouver, Canada. I was a Registered Massage Therapist for a decade and the assistant editor of ScienceBasedMedicine.org for several years. I’ve had many injuries as a runner and ultimate player, and I’ve been a chronic pain patient myself since 2015. Full bio. See you on Facebook or Twitter.
- “The Dark Truths Behind Our Obsession With Self-Care,” Shayla Love, Vice.com.
- Civilization Survival Tips — Coping with stress and anxiety in the modern world (without drugs)
- “The Mindfulness Conspiracy,” Ronald Purser, www.theguardian.com. “It is sold as a force that can help us cope with the ravages of capitalism, but with its inward focus, mindful meditation may be the enemy of activism.”
- “How Yoga Can Wreck Your Body,” William Broad, NYTimes.com. This “yoga bashing” piece was the New York Times most-shared article for a while in early 2011. It’s an excerpt from a forthcoming book, and describes potentially serious yoga hazards, such as stroke. Broad raises a legitimate concern about a gap between a popular belief (“most yoga is safe and beneficial”) and the more likely reality: some fairly common postures and practices are almost certainly at least somewhat dangerous, and there may well not be enough yoga-specific benefits to justify even small risks. Plus, the rationale for some extreme yoga is just total bollocks, and certainly deserves to be challenged. I’m looking forward to the book, it makes me I wish I’d been meaner to yoga in the past, and I don’t think Broad’s piece is particularly “sensationalistic” (as many yoga apologists have asserted, of course). It’s a given that any athletic activity has both rewards and risks. (Look no further than head injuries in football for a prime example.) The problem is that risks are a really rotten price to pay for many of the more ridiculous motives for bothering with yoga in the first place. It’s not a perfect article by a long shot. After a too-positive initial review on Facebook, many of my readers pointed out valid science-based criticisms, primarily that Broad relies quite heavily on anecdotes, and in particular concludes the piece with a doozy based on pure speculation: that decades of yoga was the direct cause of a severe case of spinal stenosis, which is really not a safe assumption at all (stenosis happens, with or without yoga). The worst case scenario is that the article is fear mongering based mostly on a handful of nasty anecdotes without citing much in the way of real risk/benefit data. For instance, for all we know, average yoga injuries per hour may be less than soccer, or even showering ... and we can't do a real risk-benefit analysis without that information.
More about back pain
- Nerve Pain Is Overdiagnosed — A story about nerve pain that wasn’t really nerve pain
- Don’t Worry About Lifting Technique — The importance of “lift with your legs, not your back” to prevent back pain has been exaggerated
- Chronic Low Back Pain Is Not So Chronic — The prognosis for chronic low back pain is better than most people realize … especially for Australians in Australia!
- The Mind Game in Low Back Pain — How back pain is powered by fear and loathing, and greatly helped by rational confidence
- 6 Main Causes of Morning Back Pain — Why is back pain worst first thing in the morning, and what can you do about it?
- The Bath Trick for Trigger Point Release — A clever way of combining self-treatment techniques to self-treat your trigger points (muscle knots)
- Natural Imperfection — Evolution doesn’t care if you have back pain … just as long as you can breed
- Does Posture Correction Matter? — Posture correction strategies and exercises … and some reasons not to care or bother
- Wobble Cushions for the Chair Bound — Why and how people who have to be in a chair all day should sit on a stability cushion like the Disc o Sit or SitFit
- The Trouble with Chairs — The science of being sedentary and how much it does (or doesn’t) affect your health and back pain
- Get in the Pool for Pain — Aquatic therapy, aquajogging, water yoga, floating and other water-based treatment and injury rehab options
What’s new in this article?
Oct 26, 2019 — The first update to this article in more than three years is minor but hilarious: snarking about the corporate yoga prescription thing.
2016 — Science update: added a citation to Bower et al, which is very positive about the health benefits of mind-body therapies — a welcome injection of optimism into this article.
2007 — Publication.
- A great example from my mail bag: a young reader with harsh back pain asked me if the answer to his pain is to study yoga. Full time. For a year. In India! No. Probably not. Unless he’s Indian. Unless studying back pain full-time in India was a genuine dream for him before the back pain, for other reasons. It is not clear that yoga deserves an investment of four hours a week … let alone a complete lifestyle overhaul.
- Bower JE, Irwin MR. Mind-body therapies and control of inflammatory biology: A descriptive review. Brain Behav Immun. 2016 Jan;51:1–11. PubMed #26116436 ❐ PainSci #53640 ❐
This is a qualitative review of 26 randomized controlled trials of the biological effects of mind-body therapies like Tai Chi, Qigong, yoga, and meditation. The studies show “mixed effects” on inflammation (CRP, IL-6, stimulated cytokine production, etc), and more consistent results for “genomic markers.” Based on this evidence, it seems likely that these activities are meaningfully good for you, and probably helpful for some kinds of chronic pain.
- People keep writing to me, “Tch tch, Paul, yoga is totally mainstream!” But I disagree. If you live in downtown Vancouver, it’s certainly mainstream. Yes, you can buy yoga mats at Walmart. But I grew up in a small blue collar town, and I can assure you, yoga still seems veeeeery weird to a lot of folks who aren’t living in the throbbing urban centers of our civilization. And there’s plenty of folks who moved to the big city not that long ago. Big Macs are mainstream. Yoga is not.
- Although alternative medicine is certainly now a substantial industry, it is still dwarfed by the size of mainstream medicine, and its popularity is generally exaggerated by the people selling services. Acupuncture, for instance, is nowhere near as widely utilized in North America as North American acupuncturists would have us believe.
- The kernel of this joke is not mine, but I can’t figure out where it came from originally: there are multiple variations from multiple sources.
- Farias M, Wikholm C. Has the science of mindfulness lost its mind? BJPsych Bull. 2016 Dec;40(6):329–332. PubMed #28377813 ❐ PainSci #53075 ❐
- Büssing A, Ostermann T, Lüdtke R, Michalsen A. Effects of yoga interventions on pain and pain-associated disability: a meta-analysis. J Pain. 2012 Jan;13(1):1–9. PubMed #22178433 ❐
The bottom line: “This meta-analysis suggests that yoga is a useful supplementary approach with moderate effect sizes on pain and associated disability.”
- Sherman KJ, Cherkin DC, Erro J, Miglioretti DL, Deyo RA. Comparing yoga, exercise, and a self-care book for chronic low back pain: a randomized, controlled trial. Ann Intern Med. 2005 Dec;143(12):849–856. PubMed #16365466 ❐
From the abstract: “Yoga was more effective than a self-care book for improving function and reducing chronic low back pain, and the benefits persisted for at least several months.” However, it was not more effective than a “conventional therapeutic exercise class.”
Note that the authors conducted a similar study in 2011, comparing yoga and stretching classes, with essentially identical results: see Sherman for more detail.
- 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 ❐
This experiment compared the effects of yoga, a normal stretching class, and an educational booklet on chronic low back pain. The primary findings were that both yoga and stretching seemed to be modestly effective, but neither was better than the other. Back in 2005, the same authors got similar results comparing yoga to conventional therapeutic exercise.
The research has been widely reported as “stretching and yoga work,” with a few writers emphasizing that yoga was no better. However, I haven’t seen anyone report that both stretching and yoga are equally damned here with faint praise, and quite possibly illusory praise: the effect size was modest, just 2.5 points on a scale of 11, and some or all that effect may well be attributable to bias and frustrebo (frustrated placebo) caused by a lack of blinding. Subjects deprived of either a lovely stretching or yoga experience may have reported a more negative experience.
I analyze this study in greater detail in my advanced tutorial, Complete Guide to Low Back Pain
- NYTimes.com [Internet]. Broad W. How Yoga Can Wreck Your Body; 2012 Jan 7uary [cited 14 Jan 6].
- There are people who apologize for yoga? Oh, yes. Seriously. Yoga has many characteristics of a religion, after all. 😉
- Farias 2016, op. cit.“… although some people may benefit from its practice, others will not be affected in any substantive way, and a number of individuals may suffer moderate to serious adverse effects.”
- Farinatti PT, Brandão C, Soares PP, Duarte AF. Acute effects of stretching exercise on the heart rate variability in subjects with low flexibility levels. J Strength Cond Res. 2011 Jun;25(6):1579–85. PubMed #21386722 ❐
This study of stretching found that
multiple-set flexibility training sessions enhanced the vagal modulation and sympathovagal balance [that’s good] in the acute postexercise recovery, at least in subjects with low flexibility levels. … stretching routines may contribute to a favorable autonomic activity change in untrained subjects.
This seems like a fairly straightforward bit of good-news science about stretching. It’s not a surprising idea that movement would have some systemic regulatory effects (motion is lotion, use it or lose it), but it’s nice to see some corroboration of that common sensical notion, and it’s also nice to know that perhaps just stretching did this (to the extent we can learn anything from a single study). If true, it makes for nice evidence to support a general stretching habit, yoga, mobilizations, really any kind of “massaging with movement,” and probably even massage itself.
- Moyer CA. Affective massage therapy. Int J Ther Massage Bodywork. 2008;1(2):3–5. PubMed #21589715 ❐ PainSci #54758 ❐
Dr. Christopher Moyer explains that the only confirmed benefits of massage are its effects on mood (“affect”), specifically depression and anxiety. “Together, these effects on anxiety and depression are the most well-established effects in the MT research literature. They are especially important for us to understand not only for their own sake, but also because anxiety and depression exacerbate many other specific health problem.” He proposes that “the time is right to name a new subfield for massage therapy research and practice: affective massage therapy.”