Why physical therapy, exercise and yoga did not help your low back pain. Ligamentous spinal instability.

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

Many people will try physical therapy, exercise, yoga, Pilates, and other activities to alleviate their back pain. For many people, these exercises will be extremely beneficial. For others, benefits may be lacking. When physical therapy and exercise have been tried and pain and disability have gotten worse, the next step is the surgical recommendation. But why would physical therapy and exercise fail? For one thing, your clinicians may have told you that your degenerative disc disease is too far gone. At this point, steroids or painkillers may help, but surgery should be explored.

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 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.

If you recognize this as being a similar situation to yours, you may also recognize that this sample story above did not include many parts and recommendations for treatments that you may have also been suggested:

But still, at the last visit to your doctors, you were told, “Only back surgery can help.” But how did you get here? Why didn’t these conservative treatments work? In this article, we will examine physical therapy, exercise, yoga, Pilates, and other activities 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 not work for. We will also look at what people can do to make physical therapy work better and avoid unnecessary spinal surgery. Physical therapy, exercise, yoga, Pilates, and other activities do work for people. They do not work for everyone. For some, they can make the problem worse.

Article Summary: 

Part 1: The point of physical therapy is to get you to move

Part 2: Why physical therapy, yoga, Pilates, and some martial arts may not help. The answer is spinal instability from weak and lax spinal ligaments.

Part 3: Spinal instability = Ligament strength first, then muscle strength


Part 1: The point of physical therapy is to get you to move


The point of physical therapy is to get you to move and strengthen core muscles. Many, many people find the treatments very beneficial. Again, these are typically not the people we see at our center. We see the people who did not respond to physical therapy, exercise, and yoga. Here is a study from May 2021, published in the medical journal Spine examining inactivity (1).

Clearly, the benefits of movement are many.

The benefits of movement in low back pain

Many people do not want to move. They could be afraid to move because of fear of re-injury. They do not want to move because of pain. They do not want to move because of previously failed attempts at exercise. However, people need to move.

A November 2023 paper (2) from the American Institute of Mathematical Sciences published in their journal AIMS Public Health reviewed and assessed recently published 24-hour movement guidelines that:

The researchers then explored the association between meeting these recommendations and low back pain by collecting self-reported data from 2333 adults about their moderate-to-vigorous physical activity, sedentary behavior and sleep duration; frequency and intensity of low back pain; and lifestyle characteristics.

What the researchers found was:

Move, be less sedentary, get sleep, and get less back pain.

What is considered a successful exercise program? To the patient, it is any pain relief.

We all know that even the smallest pain relief is a blessing. One question of course is can pain relief be made better. The answer for exercise, pilates, and yoga, it is difficult to achieve significant pain relief.

An October 2021 paper in The Journal of Family Practice (3) asked the question, is exercise therapy an effective treatment for low back pain? The answer was ” Yes, it is somewhat effective. Exercise therapy including general exercise, yoga, Pilates, and motor control exercises have been shown to modestly decrease pain in chronic low back pain; levels of benefit (short-term less than three months)) and long-term (more than 1 year) term follow-up range from 4% to 15% improvement. . . Exercise therapy may improve function and decrease work disability in subacute and chronic low back pain. Exercise therapy has not been associated with improvement in acute low back pain. Please see our article on the Different types of conservative care treatments and injections for chronic low back pain.

Is exercise a painkiller?

A September 2023 paper in the journal Physical Therapy in Sport (4) tried to help answer the controversial question, is exercise a painkiller? The authors suggest that while performing a single bout of exercise often leads to an acute reduction in pain sensitivity (i.e., exercise-induced hypoalgesia) in healthy young individuals, there is a large body of research showing that the exercise-induced hypoalgesia is diminished or impaired in people who suffer from chronic pain and older individuals. Exercise training is widely promoted for its overall health benefits across different population groups. However, whether or not exercise training can reduce pain in people with chronic pain or who are more aged, is unclear.

Do psychological factors and central sensitization symptoms explain why exercise did not help your back pain? Is exercise a true painkiller? Another opinion.

In December 2022 researchers publishing in the journal Pain Practice (5) looked for why exercise helped some patients with low back pain and did not help others. Here is what they wrote: “Exercise is the most recommended treatment for chronic low back pain and is effective in reducing pain, but the mechanisms underlying its effects remain poorly understood. Exercise-induced hypoalgesia (pain-reducing capacities) may play a role and is thought to be driven by central pain modulation mechanisms (pain sensation changes in the brain). However, Exercise-induced hypoalgesia appears to be disrupted in many chronic pain conditions and its presence in people with chronic low back pain remains unclear.”

What the researchers are saying is that Exercise-induced hypoalgesia does not work for everyone and it is not clear why it may not be effective in chronic low back pain patients. To test this thinking the researchers asked patients with and without lower back pain to perform wrist exercises to see if these exercises had any impact on low back pain. The patients with no back pain were used as a control group. What they found was in some patients the wrist exercises did not “wake up” the exercise-induced hypoalgesia regions of the brain. The lack of exercise working as a pain mediator was seen as a possible alteration in pain modulation control in chronic low back pain. However, psychological factors and central sensitization symptoms may not explain the differences observed.” Then what is it? For some, it may be the spinal ligaments.


Part 2: Why physical therapy, yoga, Pilates, and some martial arts may not help. The answer is spinal instability from weak and lax spinal ligaments.


Rear view of spinal skeleton showing ligaments and nerves

There are many reasons why exercise and physical therapy may not help your low back pain. In this article, we are going to suggest that this can be a problem of weak spinal ligaments. Before we do, let’s look at some of the other reasons given for exercise failure for chronic low back pain.

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 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 strengthening the spinal ligaments. The ligaments are the small “rubber band-like,” connective tissue that holds your vertebrae in place. However, for some researchers, an answer to why physical therapy did not help is found in the belief that the “right” physical therapy may not have been recommended.

“Many physical therapists seem not to follow evidence-based guidelines when managing musculoskeletal conditions.”

A June 2022 study led by Duke University (6) found physical therapists frequently treat patients with low back and neck pain. However, it has been established that there is significant variability in the care provided to patients with low back and neck pain by physical therapists despite the existence of clinical practice guidelines (CPGs) to treat these conditions. The study authors cite a 2019 paper from the University of Sydney which states: “Many physical therapists seem not to follow evidence-based guidelines when managing musculoskeletal conditions.” (7)

In simplest terms, treatments of the evidence-based guidelines are designed to reduce pain, increase function, and help the patient self-manage their conditions to help them avoid surgery. Typically it is the failure of physical therapy to alleviate pain that will support the use of surgery to assist the patient.

Returning to the Duke study, the researchers questioned why if adherence to evidence clinical practice guidelines can decrease the use of ineffective treatments, decrease costs of treatment, and improve patient outcomes why is adherence to clinical practice guidelines (CPGs) which can improve care in patients with low back pain and neck pain, why does treatment continue to be variable?

The researchers speculated that this variability in treatment may be due to the implementation strategy, or lack thereof, of clinical practice guidelines. In citing the second study from the University of Sydney, a survey of clinicians revealed that 54% of physical therapists chose treatments recommended by clinical practice guidelines, 43% chose treatments that were not recommended, and 81% chose treatments that have no recommendation. Why? They speculate many clinicians are unaware or lack basic knowledge or awareness of these clinical practice guidelines. They also suggest that the therapists are going out on their own and trying non-recommended treatments to help a patient who is not responding.

Compounding all this was the inconclusive findings that some recommended therapies worked better for acute pain as opposed to chronic pain and the success of recommended treatments in a few studies matched those of non-recommended treatments. In the end, the researchers wrote: “The ability to compare functional outcomes across studies is limited due to the lack of consistent outcome measures utilized. It is important to note that the majority of the studies that found improvements favoring guideline adherence . . . but the results are inconclusive when comparing pain and physical function outcomes.”

“Sixty-three percent of the physiotherapists gave guideline-inconsistent recommendations regarding work.”

In April 2023, researchers writing in the International Journal of Environmental Research and Public Health (8) wrote that in a survey of 527 physiotherapists, only “38% reported being familiar with guidelines for the management of low back pain. Sixty-three percent of the physiotherapists gave guideline-inconsistent recommendations regarding work. Only half of the physiotherapists recognized the signs of a specific low back pain.”

Many patients will tell us that their experiences with physical therapy are often disappointing. Failed physical therapy is a primary reason for someone to be sent to what may be 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 to the spine and core muscles needed 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 (9) 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 was 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 report 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 that 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 previous spinal surgery.

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 stories 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 for 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, spasms, and low back pain.


Part 3: Spinal instability = Ligament strength first, then muscle strength


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

What are we seeing in this image? Some of “the core”

The tensor fascia lata muscle is a stabilizing muscle often referred to as the “core” muscle since it attaches 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.

What are we seeing in this image? The complexity of the back muscles.

This illustration reveals the complexity of the back muscles. Back muscles and core muscles are the 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 strengthened, repaired ligaments.

Wandering vertebrae

In this short video below, we can see that on the left, the vertebrae are wandering, it is not being held in place by the ligaments. When the vertebrae are not in place, the muscle attachments to the bone, the tendons, are now being stretched. This is a case where stretching is not a good thing as it is weakening the muscle attachment and reducing resistance thereby negating the effects of strength and core training.

Look at the yellow arrows on the left and how far off the L5 is from S1.

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 don’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 (10) 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 come from the Annals of Internal Medicine, Patient Information Recap of the Study.

Yoga works were demonstrated in January 2022 and published in the medical journal Spine (11). In this paper, doctors examined the effect of a stretch and strength-based yoga exercise program on neuropathic pain in patients suffering from lumbar disc herniation. The doctors felt that yoga would be of benefit to their patients because “most yoga poses include the parameters of spinal training and help reduce pain and disability in patients with low back injuries. We hypothesized that yoga positively affects both lumbar disc herniation and neuropathic pain by increasing mobilization, core muscle strength, and spinal and hamstring flexibility.”

This is how the study was performed:

What are we seeing in this image? The case for strengthening the ligaments to help the core muscles

In the image below we have long muscle names and the technical description of the ligament attachment. Let’s explain it a little further.

As you can see, the lumbar interspinalis muscles are on both sides of the vertebrae. They attach to the vertebrae at the spinous processes (the back of the vertebrae) and extend the length of the spinal column. These muscles are important for stability in both the lumbar and cervical spine, but not in the thoracic spine. While the Interspinales muscles help in many roles, their most important role is to stabilize the spine during normal back movements and to help maintain good posture. The left and right intertransversarii muscles are considered stabilizer muscles during body and trunk movements. These muscles cannot stabilize the spine if their supportive ligament attachments, and the mamillo-accessory ligaments are compromised. In other words, physical therapy and yoga will not reach maximum or any benefit in a situation of compromised ligaments.

Quick Summary learning points:

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

What are we seeing in this video?

In this video, Prolotherapist Danielle Matias, MMS, PA-C discusses a pretty common scenario of patients who are diagnosed with sacroiliac joint dysfunction but whose MRI is normal and they try some physical therapy but it doesn’t resolve the issue. The reason for this is most frequently underlying ligament laxity in the region causing SI joint instability. When ligament laxity/joint instability is found, Prolotherapy is a great option worth exploring because it stimulates ligament repair and tightening.

“There are still controversies about the effects of yoga at different follow-up periods and compared with other physical therapy exercises”

A September 2020 analysis of published research built on this theme of why yoga did not help some patients. Publishing in the journal Public Library of Science One,(12) researchers gave this analysis of the benefits of yoga and why some do not get the benefits. Here are the learning points of this analysis:

The researchers concluded: “This meta-analysis provided evidence from very low to moderate investigating the effectiveness of yoga for chronic low back pain patients at different time points. Yoga might decrease pain from short-term to intermediate-term and improve functional disability status from short-term to long-term compared with non-exercise.   Yoga had the same effect on pain and disability as any other exercise or physical therapy. Yoga might not improve the physical and mental quality of life based on the result of a merging.”

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

In January 2017, a study led by the University of Maryland was published in The Cochrane Database of Systematic Reviews. (13)

The authors concluded:

Yoga will provide benefits for 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 (14), their beliefs that yoga will provide benefits for 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 (15) 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 seemed to be more effective in the intermediate term, for the relief of pain and activity limitation in patients with chronic low back pain.

Research on tai chi

A November 2023 study in the journal Frontiers in Public Health (16) suggested that tai chi can reduce pain in patients with chronic low back pain. In a comparison with other forms of exercise, the researchers wrote: “Tai chi can increase structural flexibility and mobility, improve muscle strength and endurance, increase the tensile strength of ligaments and bursae, enhance cardiopulmonary function, and reduce stress, anxiety, and depression. Tai chi can significantly increase bone density value, improve limb motor and balance function, and effectively improve the symptoms of low back pain.  . . Tai chi can alter brain waves in the brain’s perception of pain areas (parietal and prefrontal lobes), and the brain processes relevant information more efficiently, improving proprioception in the brain centers.”

A paper published in September 2023 in the journal Topics in Geriatric Rehabilitation (17) did warn of fall risk in tai chi-type exercises. In a study of older adults in rural West Virginia churches, the researchers found older adults who walked slower and had low back pain, or joint pain, stiffness, and swelling were at greater fall risk.

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:(18)

“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 a more effective form of exercise than Pilates and dynamic strengthening for chronic low back pain.”

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

Pilates may help reduce kinesiophobia, fear of movement

Above we spoke about why some people cannot exercise. Part of that fear is fear of movement that may reinjure the back. In a July 2023 study, doctors at the University of Birmingham writing in the Frontiers in Psychology (19) published the results of their data review of seventeen studies involving a total of 1,354 individuals and the impact of exercise on their low back pain. Pilates was the most common form of exercise evaluated. Most of the studies reported a positive direction of effect in favor of exercise reducing kinesiophobia when compared to a control group. In the end, the researchers wrote: “This review supports the use of exercise for reducing kinesiophobia in people with chronic low back pain albeit with very low certainty of evidence; Pilates (especially equipment-based) was shown to be effective as were strengthening training programs. There was limited evidence available on the effects of exercise on kinesiophobia for people with chronic neck or thoracic pain and further research is required.”

The popular understanding of back pain is disc herniation is 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 (20) 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.

The Spinal ligament repair injection treatment option Prolotherapy

Summary and Learning Points of Prolotherapy to the low back

For more information on the combined use of PRP and Prolotherapy please see Prolotherapy treatments for lumbar instability and low back pain.

Summary 

For the chronic low back pain patient where lumbar instability has been identified, the source of the pain is most commonly due to spinal ligament laxity. Physical therapy modalities, such as TENS units, electrical stimulation units, massage, and ultrasound, will decrease muscle spasms and permanently relieve pain if muscles are the source of the problem. The chronic pain patients’ muscles are in spasm or are tense usually because the underlying joint is hypermobile, or loose, and the muscles contract in order to stabilize the joint. The reason that these treatments will not work is that chronic muscle tension and spasm is a sign that the underlying joints have ligament injury.

Manual manipulation is a very effective treatment for eliminating acute pain by realigning vertebral and bony structures. Temporary benefit after years of manipulation treatment is an indication that vertebral segments are weak because of lax ligaments. Continued manipulation will not strengthen vertebral segments, and will more likely make the condition worse.

Questions about our treatments?

If you have questions about your pain and how we may be able to help you, please contact us and get help and information from our Caring Medical staff.

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References

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This article was updated February 20, 2024

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