Showing posts with label safety. Show all posts
Showing posts with label safety. Show all posts

Getting Clearer on Yoga and the Risk of Injury (Rerun)

by Baxter

A Clear Day on Mount Tamalpais by Brad Gibson
If you have not had a chance to read Nina’s Monday post (see Not All Yoga Poses Are Created Equal) about the New York Times article How Yoga Can Wreck Your Body, please do, because she articulates some very important points to consider as you digest all this hype coming from William Broad, a New York Times writer. In addition, you’ll find my take on this issue on Yoga Journal’s blog, where I am an occasional guest blogger (see here).

Before getting into recommendations for modifying specific poses to reduce the risk of injury, I’d like to step back today and look at what we know about key areas of the body that are at risk of injury from an unbalanced asana practice. What do I mean by an unbalanced practice? In my view an unbalanced practice is one where you are doing one or more of the following:
  • Practicing at an incorrect level of difficulty for your present level of expertise 
  • Doing the same poses over and over, increasing your risk of repetitive stress injuries
  • Attending classes with an inexperienced teacher unfamiliar with guiding students who have special vulnerabilities or who is aggressive with adjustments
  • Attending a class or pursuing a home practice that has an overly competitive quality to it
Well, you get my drift. One of the few studies that has tried to get a handle on this topic of yoga-related injuries was published in 2009 in the International Journal of Yoga Therapy by Loren Fishman, MD, et al (see here). He and his colleagues surveyed 33,000 yoga practitioners from around the world, got back 1336 responses, and compiled the results. In descending order, the areas of the body most affected were as follows, with the number of times reported in parenthesis beside it: neck or cervical spine (674), shoulder, including rotator cuff (661), low back, including sacrum, SI joint, sciatica (644), knee (597), wrist (414), back or spine - any area (392), hamstring (332), hip (112), leg - including ankle and foot (64), and groin (52). There were other areas also mentioned, but at much lower frequency, including elbows, headaches and nausea.

What does this mean for you and me?  Should we be overwhelmed and fearful? Probably not. Remember, only four percent of the surveys sent out were returned, so we still have a relatively small sample of folks here. What we can say is that, just as Nina pointed out Monday, any physical endeavor has some inherent risk of injury to it. However, if we keep returning to the essential quality of mindfulness and honesty in our practice, we can go a long way in minimizing the risks of injury. I can honestly admit that I have injured myself on several occasions, once from inattention in class, once from being in over my head in an advanced class I was not ready for, and once when my ego decided I should do an advanced pose that my hamstring had other ideas about. But I have also had several injuries, yoga related and not, that improved and healed through mindful and attentive practice of yoga asana.

In my next post, I’ll look at Fishman’s number one area of injury, the wrists, with some ideas and recommendations on how to approach poses that are more risky for us ordinary humans! Until then, keep on practicing.


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Friday Q&A: Forward Bends and Osteoporosis

Standing Forward Bend (Uttanasana)
One of our readers left the following comment on our post Featured Sequence: Mini Sun Salutation:

I am surprised you are including a deep forward bend. Research supports avoiding forward bends in osteoporosis and osteopenia and considering there are over 54 million people with osteoporosis and many don't know they are osteoporotic it seems safer not to teach forward bends for healthy aging. I think we have a higher percentage of yoga practitioners who fit the risk profile....slight, female, white, especially if they had a restricted diet in their younger years. 

This reader is concerned about practitioners who may have osteoporosis doing deep forward bends as we showed in our Mini Sun Salutation. And, indeed, for those with OP or even undiagnosed OP (they have it but don’t know it yet) forward folds hold the potential of increasing the risk of the most common fracture in those with OP: a wedge fracture of the thoracic spine. So, if you fall into this camp, I’d recommend modifying your standing forward bends by allowing your knees to bend as much as you need to help release your pelvis over the thigh bones as you bend, and maintain a more neutral alignment of your spine as you go down. That means avoiding rounding your upper back in the area of your thoracic spine.

I have a student in one of my class in her late 60s with recently diagnosed OP, and we discussed her modifying her forward bends in just this way for poses such as Standing Forward Bend (Uttanasana) and Widespread Standing Forward Bend (Prasarita Padottansana), and she has been diligent about doing so.

Having said all that, I’d like you to keep in mind that our blog is not just for older adults who might have or be at risk for OP—or any condition for that matter. So, the Mini Sun Salutation post was really just an opportunity for us to share with you a basic common modern yoga practice that you can refer to as needed. We will try to add in a few more cautions to these sequences in the future, but you should always read our posts on yoga poses and sequences through the lens of your own personal situation, and take good care of yourself by making any modifications to the poses to better serve your needs. And if you are uncertain as to the safety or appropriateness of any YFHA recommendations, check things out with your local teachers. 

—Baxter

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Friday Q&A: Forward Bends and Safety

Q: Recently I was working with a personal trainer who has his masters in exercise science.  He said that the recent thinking on forward bends is that no one should do a full forward bend because it puts too much pressure on the low back.  Would you be willing to weigh in on this perspective?

A: So my interpretation of your question is: in general should we practice forward bends? The question depends on a lot of issues. It is true that in flexed positions (where the spine is in a forward bend) there is a significant increase in the pressure that is placed on the vertebral disc. When you bend forward, the anterior or front part of the intervertebral disc is compressed and, for a younger population, this will cause the soft squishy center portion (the nucleus propulsus) to be directed in a posterior or backwards position. Conversely, when you extend or back-bend your spine, the discal material is pushed anterior or forward and when you side bend or rotate the discal material is sent in the opposite direction of the action. The fact that the discal material is mobile is a good thing because it is a shock absorber and our spines are meant to move in multiple directions. In us older folks, however, the interdiscal material gets dehydrated and "desiccated," so it doesn't absorb force as well as in younger folks and it is significantly less mobile. Therefore, in older folks, the development of spinal arthritis is more common because the shock-absorbing qualities of the intervertebral discs are compromised.

Now the conundrum is: what happens when we go into a forward bend position, either from standing or sitting?

In standing when you bend forward to touch your toes, there are a lot of factors affecting the force onto the spinal discs. The vertebra are structured to move in a sequential fashion so if you start the forward bend by dropping your head to your chest and allow the thoracic spine to follow the motion down to the lumbar and then to the sacrum, each vertebral level is participating in this spinal flexion or forward bend. The problem is that if there isn't good spinal mobility, certain areas of the vertebra may move more than is good for them because other areas are stiffer so don't move as much. In this case, certain parts of the spinal vertebra are overworked and over time there will be degenerative changes in the spinal discs at these levels due to overwork and poor inter-segmental vertebral movement.

Also, the force exerted onto the spinal vertebra will be greater if you bend forward from standing compared to bending forward from a seated position. Couple the standing forward bend with tight hamstring muscles, then as soon as you bend forward your hamstrings will pull your pelvis in a posterior or backwards direction rounding your lumbar spine increasing stresses on the lumbar discs. But if you do my forward bend with bent knees to take my hamstrings out of the equation then you will be putting less stress on your lumbar spine, allowing it to follow with the levels above moving first translating lastly to the lumbar mobility.

If you bend forward from standing while keeping your lumbar spine in “neutral,” then you reverse your lumbar curve only at the end into full flexion, and this is a healthier way to forward bend. But to keep my lumbar spine in "neutral" takes both hamstring flexibility and awareness.

Now let’s move onto seated forward bends. A common beginner seated forward bend is the straight-legged forward bend, Paschimottanasana. If you sit without your pelvis raised on a support and have tight hamstrings, sitting with your legs extended will pull your pelvis posteriorly and you are already in a forward bend just by sitting there in our thoracic and lumbar vertebral regions! Then if you bend forward and use your arms to “pull” yourself into the pose and ignore your breath to release into the pose, then the chance of significant injury can occur because you are maxing out your safe and available forward bend! Instead, use props. Start by sitting on a lift, such as a folded blanket or bolster, to bring your lumbar spine back into its natural curve. Then add a second prop, such as rolled blanket or bolster, underneath your knees and bend your knees slightly over the prop to remove pull of the hamstrings. This way, you can learn to move from your hips as your forward bend safely and gently!

In general, I do not agree that we should not practice forward bends. The research your trainer alludes to isn’t, in fact, very recent.  What is new is that there is a way to learn how to do forward bends that can be safe for your back as well as quieting for your central nervous system. I don't believe nor teach to "never" but I do proceed with caution. Someone who has a hot herniated disc or is recovering from spinal surgery should not do forward bends in the acute phase or recent post-operative phase. And someone who has chronic pain from spinal surgery or adhesions from prior surgeries or is just plain stiff and in pain needs to learn how to move safely within his or her own parameters of mobility and with an easy breath. Finally, we need to respect poses that historically have caused us pain or injury in the past.

Forward bends done with care, attention to mobility deficits, and with awareness of your breath to allow the release into the pose can be wonderfully nourishing to your central nervous system. Learning to find that quiet place within a pose is part of the beneficial aspect of asana. Sometimes no matter how you modify a forward bend it isn't accessible, so in those cases taking a break from doing forward bends and revisiting them later is part of the process. Good luck in enjoying the benefits of forward bends!


—Shari



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Spinal Movements: How to Keep Your Spine Safe

by Shari

We recently received this query from a reader about contraindications for spinal movements:


When are extension and flexion of the spine contraindicated. I have a patient who has issues with L5 and L6. I guess extension (backbends) would be contraindicated, correct? Also what about folks who have issues with inter vertebral discs? And what about people who have a hump in the cervical-thoracic region?


These are actually very complex questions but I will try to stay on track here. My previous post All about the Spine  gave some background on how the spine changes shape in various movements, including forward bending, back bending, twists, and side bending. Now I like to think about the spine as a train where the head on the neck is the “engine, the subsequent vertebra are the train, and the coccyx is the “caboose.”

All these separate vertebrae are connected to each other by numerous ligamentous attachments. Anterior is a long ligament that runs down the front of the vertebrae from C1-S1 and posterior is long ligament that runs down the back portion of the vertebrae. This sandwiches the vertebrae so they don’t slide forward or backward in relation to the individual top- and bottom-connecting vertebra. There are also many other types of connecting ligaments between different portions of the spine. Again, the function of all the ligaments is to keep the spine stable, and to allow coordination of movement but not too much movement at specific vertebral levels!
Anterior and Posterior Long Ligaments of the Spine
Now the interesting thing about ligaments is that they don’t have much stretch to them. In fact they don’t really stretch at all because they are stabilizing structures. What that means is that they limit movement in the spine. This is a good thing since the spine houses the spinal cord.We really don’t want to tug or pinch our spinal cord because it is the main power house that connects our brain literally to our bones and muscles and allows us to move when and how we want to.

Between each vertebra sits a cartilaginous structure called an intervertebral disc that is connected to both the top and bottom vertebra. The discs are the shock absorbers of the spine and they absorb the motion at each vertebral level.

Lumbar Vertebrae (L1-L5)
Now lets talk about what happens when there is a problem at a specific vertebral level. We can have “cranky” backs and sometimes it doesn’t take a whole lot to have your back “go out” (actually I dislike this expression because the back isn’t going anywhere so it can’t really go “out”). However, there can be areas of the spine that are more sensitive to movement. The question asks about L5 and L6 specifically. Now there aren’t a whole lot of people who actually do have an L6. Typically we only have 5 lumbar vertebrae (L1-L5), and L5 is often injured or fragile in a lot of people from different causes.

When there is a specific vertebral level that is injured, it is important to understand what the actual injury is because then you can understand how to take care of it.

There are specific spinal conditions where forward and backward bends should specifically avoided, including recent spinal surgeries, recent or acute disc injuries, or any acute injury where pain is a true warning sign not to proceed. For spinal instabilities like spondylolisthesis  back bends should be avoided, and if you have facet arthritis of the spine in lower back or neck, backbends may aggregate this kind of arthritis pain. Also, with rheumatoid arthritis and other conditions where ligaments are adversely affected, all yoga postures will need modifications to avoid over stressing ligamentous attachments.

But specific level vertebral injuries can be challenging because you can’t just stop that area from moving Movement allows the intervertebral discs to get nutrition and hydration. When the spine is prevented from moving whether from medical intervention (like surgery) or wearing a rigid brace to prevent movement, sometimes the injured area heals but due to immobility a lot of other areas of the body aren’t very happy. When there is a disc injury, allowing some flexion and extension is encouraged but the issue is the degree of motion. So what you can do is to learn how to move without causing further injury.

When I say it is important to learn how to move, what I mean is that often when people do forward- or back-bending asanas, the movement isn’t well distributed along the spine and certain areas take more of the movement in an unhealthy way. When vertebrae are stiff or there is a particular loss of motion in one area, another corresponding adjacent area will move more to correct the motion loss. This isn’t a conscious action but the body learns how to make due with what happens. So if the L5 doesn’t move well then the vertebra above it, L4, will begin to move more to compensate for the loss of movement at L5, and S1 (the top of the sacrum) will also move more than it should to also compensate. This motion loss can occur anywhere along the spine, though certain areas are more predisposed to motion changes and this is how problems develop.

But in situation described by the reader (issues with L5 and L6), should the student practice forward and back bends? Well, there isn’t really a simple answer. Remember, the spine needs to move. So, the answer is yes, but with careful attention to form and detail. I like to think about making the movement long and soft, not short and tight. There is always a quality of “work” in every active asana, but the key is how much work is safe? There should never be sharp point of specific pain and there should never be asymmetrical pain.

Now the last part of the question, about the hump in the cervical/thoracic region, In a previous post Kyphosis (Dowager's Hump), Baxter described several causes for this rounding of the upper back. While it is sometimes caused by a structural issue like scoliosis or osteoporosis, other times rounding of the upper back is due to long-standing postural habits and a long life of sitting at a desk working with the head in a down position. At a certain point the individual may no longer be able to correct the curvature by standing up straight. In these instances, where there is no actual medical contraindication, then gentle passive backbends are a wonderful approach to the upper back rounding.

A passive backbend over a bolster or blanket roll (lying on your back with your knees bent using a bolster or a blanket roll perpendicular to the torso) to help change the upper back curve is beneficial as long as the neck and lower back are protected so they don’t arch too aggressively. Also, learning to relax as well as stretch the diaphragm  are also helpful, which you can do with a gentle Cobra pose or  supported Upward Bow (Urdhva Dhanurasana) with a chair. Another very accessible backbend for the upper back is Supported Bridge pose (setu Bandha Sarvangasana on low blankets (one for torso and one for legs, with or without a belt tied around the legs).

Ultimately, to keep healthy, your spine needs to move daily through a full range of motion. Our daily lives limit our motion dramatically, so this is where your yoga practice plays a powerful role in spinal health. With attention to your breath, intention of non aggression in your practice, and a healthy dose of common sense we can encourage our spines to move safely in our practice. Then the key is to take these skills back into our daily lives to encourage more healthy motion.

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All About the Spine: Anatomy and Movements

by Shari

Recently in my classes and private sessions I have been receiving a lot of questions about the spine and exactly how it moves in different yoga poses. I thought I would do a blog post to summarize basic spinal anatomy and what the yoga practitioner needs to consider when practicing. I believe it is important for us to learn about spinal movements so we can begin to understand why one movement feels good to do while another movement either hurts or just doesn’t “go anywhere.” Many of our teachers are very skilled in the instructions they give us, but, for me, I always think that it is important to understand the why (I have never been very good about blindly following orders).

Let’s start with the anatomy of the spine. The spine is composed of separate vertebrae, which are separated into five regions of the spine. The cervical spine is the neck area and there are seven cervical vertebrae. The thoracic region is the area that begins at the level of the collarbones (clavicle) and extends all the way down to the waist. The thoracic vertebrae connect to the ribs, and there are 12 thoracic vertebrae and 12 paired ribs. The lumbar region begins at the bottom of the rib cage and extends into the pelvis. There are five lumbar vertebrae and the last vertebra sits on top of the sacrum. The sacrum consists of five vertebrae fused into a single bone (the five are initially un-fused at birth, but begin to fuse in our late teens). It is joined on each side to the pelvis and sits deep to the pelvic basin. At the bottom of the sacrum, we find the coccyx, which is composed of three vestigial vertebrae—our “tail” of bygone days.

It is important when learning about the spine to view it from multiple angles, including sideways, front facing and back facing. When you view it from these three angles, you can begin to appreciate the beauty and complexity of the spine. Some of the things that you may notice immediately when looking at pictures or, better yet, a three-dimensional model, of the human spine is that the various regions look different. The cervical vertebrae are petite and small in size, the thoracic vertebrae are bigger, with longer and more angled spinous processes, and the lumbar vertebrae are much more massive and substantial.

Also, it is apparent that the spine is not a rod but has four basic curves. The cervical region curves inward (concave), the thoracic spine curves outward (convex), the lumbar spine curves inward (concave), and the sacral region curves outward (convex). The shape of the spinal curves are important for transferring the load/weight. Maintaining those curves with weight-bearing forces keeps the spine healthy with minimal deterioration of joint surfaces. The cue that we sometimes hear in yoga class to keep our spine “straight” is a misnomer, because naturally the spine is curved! We don’t want to take the curves away but we do want to balance where the movement occurs.

Another point to consider is that the shape of the spine will change when we move through a range of motion in our daily lives as well as in our asana practice. Whenever we sit, stand, walk, reach, lie down, and so on, we are changing spinal position. Sometimes the adjustments are small and imperceptible, and other times they are much more global. Going from sitting to standing changes the spinal curves in small degrees, while going into a deep forward bend or backbend changes the curves more dramatically. The muscles that attach to the spine are forever working to keep the spine stable in whatever position we are in.

There are four specific movements that the spine moves through. When we bend forward and curve the spine (reversing the lordosis of the cervical and lumbar region and exaggerating the curve of the thoracic region) this is called flexion. We cause spinal flexion in forward bends whether in a chair or seated on the floor. The degree of forward bend is generally limited by our leg and back flexibility. Some very common forward bends that require different degrees of flexion could be Seated Forward Bend (Paschimottanasana) and Plow pose (Halasana), which you could think of as an upside down from of Seated Forward Bend.
Why do I say there are different degrees of flexion? Well, for someone who is very tight in their legs or in their back muscles, just the act of sitting in Staff pose (Dandasana) with a lift under their pelvis is very challenging. Their natural inclination might be to sit in a rounded back or flexed spine position to start and then when they bend forward even more this becomes an unhealthy forward bend because there isn’t good distribution of the change in the spinal curve.

For the tighter student, learning to sit with their spine in neutral curves is the way to begin practice for spinal safety. The student who has a lot of flexibility in their hamstrings may have tight back muscles so when they bend forward there is no change in their spinal curves—both examples are extremes.

The key to healthy forward bends, whether in Paschimotanasana or Halasana, is for there to be “ease” in the bend.  The same principles apply to standing forward bends like Pyramid pose (Parsvottanasana). Props like chairs, bolsters, and blocks allow you to find the shape of the pose without the struggle of getting into a pose you aren’t ready for.

The opposite of flexion is extension. In extension, the curves of the cervical and lumbar region are deepened and the curve in the thoracic region is lessened. We extend our spines in classic backbends like Upward Bow pose (Urdva  Danurasana) Upward-Facing Dog pose (Urdva Mukha Svanasana), and Camel pose (Ustrasana).
Of course, our spines can also twist, as when we turn to look behind us in a car. We twist our spines in seated twists, such Bhajrajasana, or Marichyasana, and in standing poses, such as Triangle pose (Trikonasana) and  Revolved Triangle pose (Parivrtta Trikonasana). And in certain poses we combine both flexion and twisting as in Parivrtta Janu Sirsasana. Poses with both extension and twisting are less common, but one example is the One-Legged Downward-Facing Dog pose with a twist.

Finally, we can side bend, as when we reach down to pick up something like a handbag or grocery bag that is next to our foot. We side bend our spines in side-bending yoga poses, such as Gate pose (Parighasana). And in many poses we combine both side bending and twisting, such as in Triangle pose (Trikonasana) and and Revolved One-Legged Forward Bend (Parivrtta Janu Sirsanana). Generally, we don't purely side bend without some twisting or purely twist without some side bending, though the primary movement will look like side bending or rotation.

The key concept to protecting your spine in all your poses is understanding where we want to encourage the movement and how to distribute the movement so as not to cause excessive motion  at one vertebral level. Another key concept is to avoid using momentum to push through “resistance.” When we are overly aggressive in attempting to gain motion this is where injury will surely occur.

So let’s break down this concept of spinal motion a bit more. If we understand that different parts of our spine move more in certain movements, does this mean that certain asanas will affect different parts of the spine differently? Yes, absolutely! The cervical and lumbar regions are concave when the spine is at rest. When we move into a backbend, these areas become more concave in relation to the curve reversal of the thoracic region. Because the thoracic region is stabilized from the front (anteriorly) by the rib cage and from the back (posteriorly) by the long spinous process, there is relatively less curve reversal from convex to concave in this region. As we move into a forward bend, the rounding of the thoracic curve increases into more of a convex shape. The opposite occurs in the cervical and lumbar spines; they start in relative concavity and as the forward bend moves throughout the spine, their shape changes from concave to relatively convex.

In twists, it is important to encourage full spinal involvement, but also to understand that the majority of the twist will occur in the cervical region, followed by the thoracic region and lastly the lumbar region. There is very limited rotation of the lumbar vertebra due to their specific structural construction. Also, please try to avoid allowing your spine to round or flex whenever doing twists. The key to healthy twists is to keep the spine long, with a good conscious control of maintaining the curves as you twist. This is often erroneously called keeping the spine “straight”, but now you know better when you hear this cue from a teacher!

When you practice, try to picture how your spine changes shape from the starting position into the position of the asana and then back to starting position. This is your experiential anatomy lesson of flexion (forward bending) and extension (backward bending), and twists. 
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Lowering Your Blood Pressure

by Nina

If you have high blood pressure—or even high blood pressure that is being controlled with medication as Timothy wrote yesterday—there are certain anti-stress poses that you should not be doing. Although inverted poses can lower blood pressure due to the interaction between your baroreceptors and your nervous system (see Why You Should Love Your Baroreceptors), going upside down initially raises your blood pressure before feedback from the baroreceptors to the nervous system causes the Relaxation Response to kick in. This initial rise in blood pressure is why the poses are considered dangerous for those whose blood pressure is already high (and perhaps for those whose blood pressure is being controlled with medication as Timothy wrote in Keeping Yoga Safe for People with High Blood Pressure), because there is concern it could cause a stroke.

Timothy didn’t list exactly which inverted poses besides Headstand that people with high or even controlled high blood should be avoiding, so I decided to talk with Baxter about the topic in order to list them out for you. The good news is that Baxter considers three of the most effective stress-reducing inversions to be generally safe. I’ve divided the inverted poses into same three groups I used in my post All About Supported Inversions. So here goes:

Full Inversions: Poses to Avoid

  • Handstand (Adho Mukha Vrksasana)
  • Forearm Balance (Pincha Mayurasana)
  • Scorpion (Vrschikasana)
  • Headstand (Sirsasana)
  • Shoulderstand (Sarvagasana), including the chair version
  • Plow (Halasana), including the chair/bench version
Because you are fully inverted in these poses, the blood quickly rushes toward your head, initially raising your blood pressure. In addition, most of these poses are stressful to perform, especially for beginners, and the stress itself can raise your blood pressure.

Half Inversions: Poses to Evaluate

  • Downward-Facing Dog pose (Adho Mukha Svanasana)
  • Standing Forward Bend (Uttanasana), with or without support
  • Wide-Legged Standing Forward Bend (Prasarita Padottanasana)
Poses where your head and torso are inverted but your legs not, such as Standing Forward Bend, are probably safe. But Baxter recommends that you ask your teacher to look at you while you are doing the poses. The same questions about how you look in the pose that Timothy listed yesterday would be helpful for assessing the suitability of these poses for you or, if you’re a teacher, for your student.

“Does the student appear to have the strength and flexibility to do the pose safely? How is their breathing in the pose? Do they look uncomfortable? Are they able to maintain a healthy curve in the neck? Are their neck veins bulging? How do they say they feel in the pose? It is even possible, if you've got a blood pressure device, to measure the pressure to make sure it isn't spiking in the pose or poses you're concerned about.”

If the pose is difficult or stressful for you, you may want to exclude it from your practice. If you decide to exclude these poses, you can practice Half Downward-Facing Dog pose at the Wall instead.

Gentle Inversions: Poses that are Generally Safe

  • Legs Up the Wall pose (Viparita Karani)
  • Easy Inverted pose (Viparita Karani with bent legs)
  • Supported Straight Leg Bridge pose (Setubanda Sarvangasana)
According to Baxter, gentle inversions where your heart is only slightly higher than your head and your body slopes gradually down, such as Legs Up the Wall pose, do not seem to cause an initial rise in blood pressure (he has done some informal testing). Therefore, he feels comfortable in saying they are generally safe. One caveat might be that if your blood pressure is wildly out of control, it might make sense for you to do a different type of practice for stress reduction (see below).

Safe Ways to Lower Blood Pressure
Remember, there is no need for you to do any inverted poses! If you are at all concerned about going upside down, you can choose from several other very effective and safe techniques for lowering your blood pressure. Any yoga or meditation technique that triggers the Relaxation Response (see The Relaxation Response and Yoga) will lower your blood pressure (this was proven in the 70s by Dr. Herbert Bensen and described in his book The Relaxation Response, which I highly recommend). Probably the easiest thing to do is just to sit quietly and observe your breath or recite a mantra. But you can practice any form of mediation, practice Yoga Nidra, any guided Savasana, or any form of Relaxation pose (Savasana) with a mental focus. You could also practice your favorite restorative poses (see Mini Restorative Practice, also with a mental focus. Just be sure to take a non-judgmental attitude toward your practice, give yourself at least 10 to 20 minutes of practice, as it takes a while for the Relaxation Response to kick in, and don’t fall asleep (sleeping is different than conscious relaxation).

All of these options are wonderful for anyone who experiences “situational” high blood pressure (when getting stressed out or angry causes... well, you know!) And practicing conscious relaxation on a regular basis will also enhance your health in the short term (bolstering your immune system) and the long term (helping to prevent heart disease, strokes, and other diseases of aging).


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Keeping Yoga Safe for People with High Blood Pressure

by Timothy

Monterey Cyprus by Melina Meza
I recently taught a course on Yoga for High Blood Pressure on Yoga U Online. During the program I suggested that doing certain inverted poses such as Headstand (Sirsasana) may not be a good idea, even for some people whose blood pressure (BP) is “well controlled” by medications. But one listener had heard during her teacher training that inversions were okay in this situation. Her instructors had consulted a local cardiologist and shown the doctor the poses in question, and he had said he didn't have a problem with them in people whose BP was under control.

The concern is that when you go upside down, the pressure in the head increases, which could at least theoretically increase the risk of a stroke. I say theoretically, because actually no one really knows how large the risk is, though it's likely very, very small. As I've written elsewhere, more than likely yoga greatly decreases the overall risk of a stroke. But that doesn't mean it's a good idea to push your luck.

Interestingly, blood pressure is one area where yoga teachers are sometimes more conservative than doctors. Aadil Pahkivala, the teacher I worked with on the high blood pressure chapter of my book Yoga as Medicine, has found that some people with well-controlled BP nonetheless demonstrate jitteriness when they do some inversions and strong backbends. This nervous system agitation, which can be visible to the teacher and palpable to the student  (at least the ones who have developed their internal awareness though their yoga practices), suggests a potential problem.

In medical school, we were taught to always weigh risks vs. benefits of any test, drug or medical procedure under consideration. In medicine, this comes under the category of “first do no harm.” In yoga, we've got the same idea with the notion of ahimsa, non-harming, which is considered the foundation of any yoga practice. Again, the risk of a stroke when inverting with “well-controlled” high blood pressure is likely very small, but even a tiny risk of something very bad should be factored in when deciding whether or not to do a particular yoga pose. In yoga, a crucial way to assess safety is to study your student—or yourself, if you're the student in question—as they do the practice in question.

So rather than simply saying, “The doctor says it's okay to do Headstand so let's do it,” a more prudent approach is to let that be the beginning of your evaluation. If you're a teacher, consider the following questions: Does the student appear to have the strength and flexibility to do the pose safely? How is their breathing in the pose? Do they look uncomfortable? Are they able to maintain a healthy curve in the neck? Are their neck veins bulging? How do they say they feel in the pose? It is even possible, if you've got a blood pressure device, to measure the pressure to make sure it isn't spiking in the pose or poses you're concerned about. And if you're a student concerned about high blood pressure, ask your teacher to help you do this evaluation.

Especially when the risks are uncertain, the more information you can get the better. And after you have all the information, it’s time to practice ahimsa.
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Friday Q&A: Ostepenia of the Spine and Headstand

Q: I am 63 years old and have osteopenia of the spine. What are your thoughts of headstand for those of us with osteopenia of the spine? I have taken yoga for several years. My teachers are wonderful and all are Iyengar certified as senior teachers. I have not yet shared with them my recent diagnosis. I appreciate your thoughts on this question.

A: As a general rule, I’d say don’t do it. As we have written about before, the spine is the number one sight for fractures secondary to osteoporosis and osteopenia means your spinal bones are already thinning. And although the thoracic spine is the most common area for wedge fractures to show up in OP, lumbar and cervical fractures happen, too. The human cervical spine—as you probably already realize—is not structured to bear weight on the head, no matter how much you might love Headstands and Shoulderstands (also not a good idea if you have osteopenia of the spine) or what your teachers might like to believe. The cervical region of the spine has the shortest vertebrae and the thinnest discs of anywhere in the spine, because it is evolved only to have to bear the weight of your head, not your body resting down on your head.

I also recommend sharing your diagnosis with your teacher. Now. If your teachers are not particularly concerned about the possible negative effects of Headstand on your spine, you might seek out a new teacher. This does not mean that you cannot do certain inverted postures. Legs Up the Wall is generally safe as an alternative, and if you can get up and down by pivoting mostly at the hip joints to use a “Headstander” (a special prop that allows a variation of Headstand where the head dangles toward the floor but does not rest on the floor) to go upside down, you could give that a try. But do remember that you need be careful about forward folding and it’s potential negative impact on the thoracic and lumbar spine with OP. 

As senior Iyengar teacher Ramadan Patel once said during a workshop on Shoulderstand when someone was bemoaning the fact they might not be able to do the pose again, “Nobody ever attained enlightenment doing Shoulderstand! It is not big deal. Let it go.” It was helpful to actually hear that back when I was able to do Shoulderstand and Headstand without a second thought. These days, I myself skip Headstand to keep my delicate cervical spine happier.

—Baxter


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Keeping Your Hips Happy and Healthy

by Shari

After reading Women's Flexibility is a Liability in Yoga by William Broad and responding with Is Women's Flexibility a Liability in Yoga? Shari's Response to William Broad and Differences Between Male and Female Pelvic Structures I thought some general advice about how to keep your hips healthy and happy would be helpful for both women and men alike.

I suggest you start by finding your hips and assessing your mobility. I often ask my students to begin by locating their hip joints. They are not on the outside of your pelvis but the spot where when you lift your legs up when you are climbing stairs, you feel the muscle moving under your fingers. This is the head of your femur (thigh bone).

Hip Joint Located Behind Inguinal Ligament
Next, test your own amount of leg external and internal rotation. Lie on the floor in Savasana (Corpse pose), with your feet slightly apart. Then, moving from your hips while keeping your legs straight, turn your legs out so your feet turn away from each other. This is external rotation.  As you do this motion, make sure you are doing the movement from your hips not from your lower leg/knee. Observe how far you can turn your legs out, and whether both sides are the same. Next, moving from your hips while keeping your legs straight, turn your legs in so your feet are turning toward each other. This is internal rotation. Again, as you do this exercise, make sure the movement originates from your hips not from your lower leg/knee. Observe how far you can turn your legs in, and whether both sides are the same.

Once you can sense how much actual hip rotation you actually have (and whether you are the same on both sides), you can begin to assess your own foot placements for standing poses. Start by exploring your particular hip alignment in wide-legged, side-facing standing poses, such as Warrior 2 or Triangle pose. See whether it is easier to feel your hip position if you step into your standing pose from Mountain pose (Tadasana) by stepping back with your left leg and keeping your right leg stable, rather than stepping the right leg forward and the left leg back (the traditional Iyengar yoga cue). Then, as you take your stance in the pose, first try keeping your front heel in line with your back middle arch and notice how your back leg internal rotation feels. If you find that in order to do this alignment you have to reposition your lower leg moving from your knee to correct this alignment, try a wider front heel to back heel stance and see if this feels like less tension in your knees and back hip.

I remind my students to not square the pelvis (see Squarer's Beware) but to allow the front pelvis to be in the same plane as the front knee and the back knee to be in the same plane as the back pelvis. In these types of poses, your front leg will be in external rotation relative to your back leg, which is in internal rotation. While working with your hips, don’t forget your knee positioning—to protect your knees, please align your knee with the middle of your ankle joint and generally in line with your second toe. All these joints should be lined up. Proper alignment that is optimum for you may take some experimentation, so if in you’re doubt, use a mirror to help you check exactly which direction your knees and hips are facing.

Continue this exploration in all your wide-legged standing poses, such as Extended Side Angle pose and Warrior 1. Try not to force rotation by causing your pelvis to move more than is comfortable over your stable legs. And don’t be afraid to line up your front heel with your back heel if that gives you more a sense of freedom in your hip joints! Turning one joint surface too much in relationship to another (the femur turning in the cup of the acetabula) will put stress and strain on the hip joint capsule and the ligaments that keep the hip within the socket of the acetabula.

 Some rules of thumb for standing poses:
  1. Any pain in the groin or knees need to be respected. Please back out of the position.
  2. Pay attention to pain in any body part, especially when doing single leg positions (balancing poses) and try to modify to avoid reproducing the pain. It is really important to learn how to use your muscles (which need to contract on both sides of the joints ) and bones to support your weight rather than depending on the ligamentous structures inside the joints to provide stability. Pain can come from compressing the pain sensitive structures inside joints (ligaments, tendons and capsules) or from moving beyond the joints limits of mobility (see Range of Motion: Yoga's Got it Covered).
  3. Try to avoid overly stretching the front of your thighs close to your hip crease in your back leg in poses like Warrior 1, Triangle pose, etc. And for lunges, avoid going into your end range with your back leg and “hanging out” there. 
Now on to seated poses! Whether you are sitting in a straight leg position like Staff pose (Dandasana) or in a bent leg position like Seated Crossed Legs (Sukasana), Cobbler’s pose (Baddha Konasana) or Lotus/Half Lotus, it is really important to sit with your knees below your hips. If you have limitations in your hip external rotation, you definitely need to sit on a prop (folded blankets or bolster). And if you can’t lift your pelvis up over the front of your hip joints (this will look like a slumped position), again pleased sit on a prop to allow some space so you can lengthen up and bring your spine back into its natural neutral curves.
Sitting on a Prop
Remember the spine has curves for a reason—they serve as a means to distribute weight through the spine along the vertebral bodies. If you sit in a reversed or slumped position, you change the weight-bearing forces onto the facet joints and the soft tissue structures of the back (muscles and ligaments and discs). When you sit with your bones providing the support, you will tire less and breath better!

Finally, in bent leg positions, you may need to support your outer legs to prevent the sensation of hip pain. You can place folded blankets or blocks under your knees to keep your legs from hanging in space.

Sitting in Hero pose (Virasana) is a different hip position—internal rotation. Depending on the degree of internal rotation that you have, it may or may not be possible for you to sit with your knees together. In this case, try sitting on a higher support so your pelvis can be over the heads of your femurs (thigh bones) not behind them, and allow your knees to separate but not roll out. Align your thighs with your hip joints. Try palpating your hips in Hero pose and experiment to see if changing how close together your knees are helps to make the pose more comfortable. Reclined Hero pose (Supta Virasana) is also a different hip position because internal rotation is now superimposed with a backbend and if your hips can’t move into internal rotation, then your lumbar spine and sacrum will try to compensate for the lack of movement which can also cause pain and discomfort. This is especially the case for women because our sacroiliac joints may not lock down in weight bearing in this backbend so there can be an uneven distribution of weight in the back bend position. Learning how to prop for both Hero pose and Reclined Hero pose is really important, and you may need a teacher to help you with these alignment issues.

The bony structure and joint orientation of your hips in the acetabulum of the pelvis are variables that cannot be changed. Bones can only move in certain ways due to form and function. We may try to compensate for our immobility by excessively overusing our soft tissue ligaments and joint capsules to try to gain flexibility that we lack. Or, we may inadvertently try to make our hips move beyond their anatomical possibilities by the sports that we do or the yoga that we practice because we think the goal is more flexibility. This certainly can cause excessive wear and tear of the hip joint leading to cartilage deterioration and arthritis. So the issue really is our perception of what a pose is supposed to look like. How a pose feels is very individualistic, and it is not good to struggle with a pose that always causes pain. Sometimes for some of us certain poses aren’t attainable in the classical sense, but I believe that if we can recreate the feel of the pose we can get the benefits. For example, Dancer’s pose (Natarajasana) is a challenging balancing backbend in which you raise one bent leg behind you and reach overhead with one bent arm to hold the toes of your raised foot. However, modifying this pose by reaching your straight arm back to hold your foot instead of up overhead will allow you to recreate the beauty and concentration of the classical pose.

For healthy aging, I believe that struggle may not always be the best way to go; instead, learning to be less aggressive and more adaptive is a best way to approach asana. Mental focus and alertness with concentration on using the breath to create asana is more satisfying than trying to force oneself into contortions that may not be possible for one’s innate physical structure. This is how we balance and protect ourselves from injury during the physical asana practice.
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