Why physical therapy and yoga did not help your low back pain

Ross A. Hauser, MD; Danielle R. Steilen-Matias, MMS, PA-C.

Many people will try many treatments to avoid back surgery. For others, their back or disc degeneration is not severe enough, YET, to be recommended to back surgery. So their surgeon will recommend various conservative care treatments to help them today. This will include among other things, physical therapy and yoga.

Why physical therapy and yoga did not help your low back pain

In this article, we will examine physical therapy and yoga for people with low back pain. We will look at who these treatments will work for. We will also look at who these treatments can’t work for. We will also look at what people can do to make physical therapy work better and avoid unnecessary spinal surgery.

Physically therapy and Yoga do work for people. They do not work for everyone. For some, they can make the problem worse. This will be explained below.

Now I need back surgery.

When a new patient comes to our center with back pain and a history of physical therapy and other strengthening and stretching programs, they are often confused by the lack of results, we often hear:

“I have sciatica, after physical therapy, it was worse. Now I need back surgery.”

I am waiting now for a back surgery. I have a lot of lower back pain. I have been getting physical therapy and chiropractic treatments over the last few years. Sometimes it helps, sometimes it does not help. I am doing yoga now too. It is basically the only exercise I can do. I am not sure how much it is helping but I know it is not helping enough to be able to help me avoid back surgery.

The Caring Medical experience is that the results of PT are often disappointing. Disappointing may not be the right word, perhaps dangerous would be better because failed PT is a primary reason for someone to be sent to unnecessary spinal surgery.

Physical therapy is a major component of the orthopedist’s “conservative” approach to low back pain relief. The Caring Medical experience is that the results of PT are often disappointing. Disappointing may not be the right word, perhaps dangerous would be better.

Who are these patients at risk for dangerous unnecessary surgery?

These are patients who suffer from pain caused by spinal instability from weakened and damaged spinal ligaments. For physical therapy, and as we will see later in this article, yoga and pilates, to work, a person needs strong spinal ligaments. Strong spinal ligaments provide resistance the spine and core muscles need to strengthen the core, provide stability, and make physical therapy more successful.

When physical therapy fails, patients become at risk for spinal surgery they do not need.

A paper published in the Journal of Advancement in Medicine (1) by the Department of Physical Therapy, University of Utah, Salt Lake City, wanted to evaluate whether early physical therapy (manipulation and exercise) is more effective than a consultation where the patient were simply given education on rest, activity, and standard care options.

In this study, 207 patients with an average age of 37 were monitored and followed up at one year. Here are the study’s learning points:

At one year both patient groups, those who had PT and those who did not reported the same results

The researchers, remember are physical therapists, they note: “The potential benefits of early physical therapy should be considered in light of the time and effort required to participate in physical therapy.”

The researchers were not trying to say physical therapy did not work better than educational guidelines, what they were trying to show was the physical therapy did provide benefits for many patients. Patients who were at risk for physical therapy failure should be identified sooner.

In the screening process of the study, patients with pain radiating into the knee area and clinical findings suggesting nerve root compression (suggesting lumbar radiculopathy, sciatica) were excluded, as well as patients who had a previous spinal surgery.

The goal of any treatment is to strengthen the spine.

When a patient is diagnosed with degenerative disc disease, the initial treatment response is to strengthen the spine or the “core,” muscles with physical therapy and/or relieve spasms with yoga.  to alleviate the pain. What physical therapy and yoga may not achieve is the getting the vertebrae back into their natural positions to remove pressure on the spinal nerves. Chiropractic adjustments may do this on a temporary basis but it may require constant visits to the chiropractor to achieve these results. Why these treatments may not prevent the eventual need for spinal surgery is that they do not address strengthen the spinal ligaments. The ligaments are the small “rubber band like,” connective tissue that hold your vertebrae in place. Below we will discuss injection treatments that help strengthen these ligaments.

In this image we see the effects of spinal instability on the spinal cord and spinal nerve root. Spinal instability can be caused by many problems including damaged or weakened spinal ligaments.

Quick Summary learning points:

Failure from misdiagnosis of discogenic pain as the root of a patient’s pain. Spinal instability being caused by loose and weakened spinal ligaments. 

Physical therapy for lumbar radiculopathy and sciatica? Why won’t they work? The controversy surrounds ligaments and core muscles

There is much research surrounding low back pain and physical therapy and exercise. The above study was singled out because it appeared in one of the most highly regarded medical journals in the world, the Journal of the American Medical Association (JAMA), and an article on this study appeared in the October 14, 2015 edition of the New York Times. In that article lead author, Dr. Julie M. Fritz is quoted as saying: “Most treatments that are effective have only modest effects. The pattern of low back pain is one of recurrence and remission, and changing that pattern is a real challenge. There are no magic answers.”

And this is what we find at Caring Medical when taking a patient history. The patients will tell us their story of treatment, success, remission, new pain, sometimes worse pain, back to therapy, or to the chiropractor. They will repeat the cycle until such time as the cycle is broken by pain management medication therapy or a recommendation to surgery.

What they generally do not tell us is that they went to a doctor and that doctor did an examination on their back and hip area looking for instability caused by spinal ligaments and the accompanying muscle weakness, spasm, and low back pain.

Spinal instability = Ligament strength first, then muscle strength

There are two sets of muscles in the body: mobility muscles and postural stabilization muscles.

The tensor fascia lata muscle, a stabilize muscles often referred to as “core” muscle since they attach to the axial skeleton and pelvis, which are considered the foundation of the human body.

The tensor fascia lata muscle, a stabilize muscles often referred to as “core” muscle since they attach to the axial skeleton and pelvis, which are considered the foundation of the human body.

The primary role of the core muscle systems in the lumbar spine and pelvis is to provide segmental control and dynamic stability to the spinal column it cannot be done without strong ligaments.

The lumbar region is well endowed with the core muscles, which play a role in the stability of the spine. These muscles—the abdominal muscles, the psoas major, and the erector spinae—are all actively involved in maintaining the functional stability of the lumbar spine in both upright and sitting postures. Their muscle action is especially crucial during the very high loading that the lumbar spine typically undergoes. Without these muscle forces, such large loads would cause disruptions in the lumbar vertebral column and likely result in spinal instability and severe pain.

This illustration reveals the complexity of the back muscles. Back muscles and core muscles are a primary focus of physical therapy. Spinal instability, caused by spinal ligament laxity can cause vertebrae to move out of their natural positions and cause bulging and herniation. Even a single maligned vertebrae can impact and cause dysfunction throughout the spine and core muscle groups. This will make physical therapy ineffective.

This illustration reveals the complexity of the back muscles. Back muscles and core muscles are a primary focus of physical therapy. Spinal instability, caused by spinal ligament laxity can cause vertebrae to move out of their natural positions and cause bulging and herniation. Even a single maligned vertebrae can impact and cause dysfunction throughout the spine and core muscle groups. This will make physical therapy ineffective.

Physical therapy will not make gains without without strengthened, repaired ligaments

Yoga works when there are strong ligaments, yoga will not help when ligament instability prevents muscles from getting needed resistance

Some patients with lower back pain have seen great results with yoga. Some patients have seen poor, none, or worse, results that caused greater injury to the low back. Why do some get benefits and others didn’t? How do some hurt themselves worse? The answer is ligaments.

Let’s first paint a picture by way of a comparison between yoga and physical therapy and the ligament problem.

Research that was published in the July 2017 edition of the Annals of Internal Medicine (2) helps us shed some light on realistic expectations for Yoga and Physical Therapy.

Coming from some of the best research universities in the United States, doctors from Boston University School of Medicine, Harvard Medical School, the University of Pittsburgh School of Health and Rehabilitation Sciences, and the University of Washington found:

The portions of the above in quotations comes from the Annals of Internal Medicine, patient information recap of the study.

January 2017, a study lead by the University of Maryland published in The Cochrane Database of Systematic Reviews.(3)

Yoga can be best effective when the spinal ligaments are strong. If spinal instability is the problem, yoga will not be successful for very many patients

The authors concluded:

Yoga will provide benefits from some patients

In a commentary to the above study, researchers from the United States Department of Veteran Affairs and from Rutgers University published in the journal Explore August 2017 (4), their beliefs that yoga will provide benefits from some patients. This is explained in this statement:

“Even though the evidence was of moderate to very low certainty (that yoga worked for low back pain sufferers), given its relative safety, the trends toward positive results, and the high rates of chronic pain and opioid use, yoga should be considered as a potential approach to include as part of a patient’s care plan for non-specific chronic low back pain. Similar to non-yoga exercise, yoga helps bring movement into the body. However, yoga also supports the development of body-awareness and focus on posture and alignment, as well as assists with physical and mental stress, which may be particularly important in the management of chronic low back pain. “

Just walking may be better than yoga

In August 2020, doctors writing in the medical journal Medicine (5) compared walking and mind-body therapies, including yoga, which they note are commonly recommended to relieve pain and improve function in patients with chronic low back pain. What they found was that yoga, seemed to be more effective in the short term, and walking seems to be more effective in the intermediate term, for the relief of pain and activity limitation in patients with chronic low back pain.

Pilates works when there are strong ligaments, Pilates will not help when ligament instability prevents muscles from getting needed resistance

Pilates is an exercise program that concentrates on the deep stabilizer muscles of the core. Pilates, like physical therapy, like core stabilizing exercises, can only work when the ligaments of the spine can support the exercise activity and provide resistance so the muscles strengthen.

It is very rare to see research that says one form of exercise works and another does not. They either all work or they all don’t work. Studies supporting one form of exercise over another support this idea.

Here is the last paragraph from an August 2017 study in the Journal of Exercise Rehabilitation:

“On the basis of the present study it can be concluded that lumbar stabilization exercise, dynamic strengthening exercise and Pilates are beneficial in the treatment of chronic nonspecific low back pain for reduction of pain, improvement in functional ability, increase range of motion and improve core strength.

However when compared, lumbar stabilization proved to be more effective form of exercise than Pilates and dynamic strengthening for chronic chronic low back pain.”(6)

They all worked. One a little better than the others in this one group.

The point of this article is that Physical Therapy, Yoga, and Pilates will work better if strong ligaments in the spine are present to provide the resistance necessary to achieve gains

In this video, Danielle Matias, MMS, PA-C explains and demonstrates a Prolotherapy treatment into the lumbar spine.

Video Summary and Learning Points

The popular understanding of back pain is disc herniation as a frequent cause, but to a much greater extent, ligament injury forms the underlying basis.

Caring Medical research: Our paper “A Systematic Review of Dextrose Prolotherapy for Chronic Musculoskeletal Pain,” published in the journal Clinical Medicine Insights. Arthritis and Musculoskeletal Disorders (7) made these observations supported by accompanying citations:

Without strong ligaments, physical therapy cannot work.

The entire content of this article is nicely summed up in these few words. “insufficient stability to permit effective muscle recruiting strategies.” Without the ligaments, physical therapy cannot work.

The next bullet point, from the same research, gives the solution:

In a separate study we published in the Journal of Prolotherapy,  we published these findings:

Results:

These patients were treated every three months on average.

In summary, when physical therapy does not work, then the person should consider Prolotherapy.

Ask a question about physical therapy and yoga and get help from our Caring Medical staff

1 Fritz JM, Magel JS, McFadden M, Asche C, Thackeray A, Meier W, Brennan G. Early physical therapy vs usual care in patients with recent-onset low back pain: a randomized clinical trial. Jama. 2015 Oct 13;314(14):1459-67. [Google Scholar]
2 Saper RB, Lemaster C, Delitto A, Sherman KJ, Herman PM, Sadikova E, Stevans J, Keosaian JE, Cerrada CJ, Femia AL, Roseen EJ. Yoga, physical therapy, or education for chronic low back pain: A randomized noninferiority trial. Annals of internal medicine. 2017 Jul 18;167(2):85-94. [Google Scholar]
3 Wieland LS, Skoetz N, Pilkington K, Vempati R, D’Adamo CR, Berman BM. Yoga treatment for chronic non‐specific low back pain. The Cochrane Library. 2017 Jan 12.
4 Whitehead A, Gould SF. Yoga Treatment for Chronic Non-Specific Low Back Pain (2017). Explore (New York, NY). 2017;13(4):281-4. [Google Scholar]
5 Nduwimana I, Nindorera F, Thonnard JL, Kossi O. Effectiveness of walking versus mind-body therapies in chronic low back pain: A systematic review and meta-analysis of recent randomized controlled trials. Medicine. 2020 Aug 28;99(35).  [Google Scholar]
6 Bhadauria EA, Gurudut P. Comparative effectiveness of lumbar stabilization, dynamic strengthening, and Pilates on chronic low back pain: randomized clinical trial. Journal of exercise rehabilitation. 2017 Aug;13(4):477. [Google Scholar]
7 Hauser RA, Lackner JB, Steilen-Matias D, Harris DK. A systematic review of dextrose prolotherapy for chronic musculoskeletal pain. Clinical medicine insights. Arthritis and musculoskeletal disorders. 2016;9:139. [Google Scholar]
8 Hauser RA, Hauser MA. Dextrose Prolotherapy for unresolved low back pain: a retrospective case series study. Journal of Prolotherapy. 2009;1:145-155.

3210

Make an Appointment |

Subscribe to E-Newsletter |

Print Friendly, PDF & Email
Facebook Reviews Facebook Oak Park Office Review
SEARCH
for your symptoms
Prolotherapy, an alternative to surgery
Were you recommended SURGERY?
Get a 2nd opinion now!
WHY TO AVOID:
★ ★ ★ ★ ★We pride ourselves on 5-Star Patient Service!See why patients travel from all
over the world to visit our center.
Current Patients
Become a New Patient

Caring Medical Florida
9738 Commerce Center Ct.
Fort Myers, FL 33908
(239) 308-4701 Phone
(855) 779-1950 Fax Fort Myers, FL Office
We are an out-of-network provider. Treatments discussed on this site may or may not work for your specific condition.
© 2021 | All Rights Reserved | Disclaimer