Last Updated Jun 2012
In the first ‘Healthy Spine’ article, I reviewed neutral spine posture and asana that can be done while holding neutral. This week I want to talk about how forward bends and backbends may affect some common problems of the spine.There are scores of websites out there that suggest various asana for low back pain, however very few address the individual and varied nature of pain. Most seem to assume that the pain is related to postural stress from sitting and therefore tend to emphasize back bending asana such as Cobra. While it is true that many people do have symptoms related to such postural stress, some clients may be aggravated by backbends. Let’s review some common diagnoses:
Bulging or Herniated Discs. This is a diagnosis that is common in people aged 20-something to 50-something. Patients with damage to discs often have a significant loss of lumbar lordosis. This may be as a result of or perhaps a cause of the injury. Most often discs will bulge or herniate toward in the posterior-lateral (back and to the side) part of the disc. When you flex the spine or do forward bends the bulge will worsen, possibly placing pressure on the adjacent nerve root. However sometimes bulges may be more central, which could be aggravated more by back bending.
Spondylolisthesis. This diagnosis involves forward slipping of a lumbar vertebrae. This may be due to a congenital abnormality or repetitive stress that causes a fracture in the pars intera
rticularis (bone that connects the vertebral body to the spinous process). This diagnosis is often seen in young athletes such as gymnasts and football players. These clients often have hyperlordotic posture (excessive inward curve). Lumbar extension and back bends will aggravate their symptoms Core stabilization is crucial for people with this diagnosis.
Stenosis. This diagnosis means narrowing and most typically refers to narrowing of the space where the nerve roots exit. The narrowing is usually the result of a loss of disc height and/or thickening of the bone around the facet joints which is a common manifestation of osteoarthritis. Stenosis is common in older adults and it may be aggravated by lumbar extension or back bending. These clients may feel pain with Cobra, Bridge or Warrior postures.
Osteoporosis. Flexion in the thoracic spine should be avoided by those with osteoporosis. Backbends that focus on the mid-back (such as Mini-Cobra) should be emphasized for these clients. Ideally, the scapular muscles (middle and lower trapezius, rhomboids, rotator cuff) should be strengthened to improve postural endurance. Forward bends can be done safely if the thoracic spine remains lengthened and is not rounded toward its end-range.
Sacroiliac (SI) Pain. Forward bends or lumbo-sacral flexion make the SI joints more vulnerable to injury because there is less joint congruency, in other words less stability. In a flexed posture or with the tailbone ‘tucked’ (counter-nutated), the stability of the joint is entirely dependent on the ligaments around it. Combining lumbo-sacral flexion with rotation, as in Seated Sage Twist, may force the sacrum out of alignment, especially if the ligaments are lax, either due to genetic predisposition or to a sustained, long-term yoga practice that over stretches the ligaments. Once an injury occurs, forward bends are most likely to aggravate the symptoms. 
Piriformis or Quadratus Lumborum Syndromes. Tightness, spasm or hypertonicity (holding excess tension) of the piriformis or the quadratus lumborum (QL) can mimic any of the above pathologies. But while a bulging disc or SI joint strain will most likely be irritated by forward bends, these muscular symptoms may be relieved by gentle, flexion-based stretches. Active backbends such as cobra may aggravate these patients but gentle, supported postures such as Reclined Bound Angle may provide relief as the muscles will be shortened and encouraged to relax.
This is just a glimpse into how various pathologies and impairments of the spine are related to spinal curves and how they may be affected by flexion-based or extension-based postures. Anyone with significant or persistent back pain should be evaluated by a licensed health care specialist (a neurologist, orthopedist, physiatrist or physical therapist who specializes in spine). Once the origin of symptoms has been identified, an individualized program can developed by a PT and/or yoga therapist.A program that is designed to prevent back pain for the general population should emphasize healthy range of motion in all directions: flexion and extension as well as rotation and side-bending. It should teach mindfulness of posture and breathing patterns and it should teach core muscle strength and relaxation.
In part 3 of this series, featuring Tuesday, June 12th, I will write about bandhas and their role in treatment and prevention of back pain.
About the Author: Lisa B. Minn is a licensed physical therapist and yoga enthusiast. She has been incorporating aspects of Yoga her physical therapy practice since 2001 and became a certified yoga instructor in 2004. You can read more about the therapeutic applications of yoga on her blog, ThePragmaticYogi.com.
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