Guest guest Posted May 17, 2004 Report Share Posted May 17, 2004 Dear all i am sending off this good article on Yoga Injuries that appeared in the recent issue of Yoga Studies which is published tri-annually (in January, May, and September) for members of the International Association of Yoga Therapists. Membership is $60 per year for U.S. residents, $65 for non-U.S. residents with email, $70.50 for U.S. residents without email (includes cost of providing a printout of Yoga Studies), and $80 for non-U.S. residents without email (includes cost of providing a printout of Yoga Studies). To join or renew, please fill out the online membership application form (http://www.yrec.org/promember.html) or write or call us for a printed form. it was interesting to see the comment that most people are not aware enough to know their own bodies amma made a perceptive comment when she said that thew problem lies in the modern attitude of NO Pain-No Gain and so everyone wants pain to feel that they are gaining something in the Yoga Class ananda YOGA INJURIES: THE REAL PROBLEM by Kaylan McKinney-Vialpando Introduction Who would have thought that the peaceful and beautiful practice of Yoga would turn into such a hot topic of debate, attitudes, controversy, and injury? The irony is enough to make us raise our eyebrows and shake our heads. We all know there are many different styles of Yoga, with Eastern and Western flavors and different philosophies and approaches, but with hopefully similar goals. We also know that Yoga teachers range from those who have studied Yoga seriously for years to those who are teaching from a fitness perspective, the latter often being current or former group exercise instructors. Is one type of teacher better than the other from the standpoint of injuries? That would depend on the individual, his or her knowledge base, level of dedication, purpose in teaching Yoga, and numerous other factors. There is a major misunderstanding between the two groups and I would love to elaborate on it, but that is not the purpose of this article. Instead of assuming an automatic preference for one type of teacher over another, consider what qualities are important in a Yoga teacher. On your list of qualities, did the word “safe” appear? For most people who are newly interested in the physical benefits of Yoga, safety would likely be an important issue. In fact, many people who are uncertain about, injured by, or intimidated by other forms of exercise often turn to Yoga as a perceived safe alternative for increasing their fitness and relieving stress. Unfortunately, they are being let down in increasingly larger numbers, as Yoga injuries are on the rise. I realize that some suggest it is impossible to get hurt if we truly listen to our body and practice Yoga as intended, but in my experience there seems to be just a small number of practitioners who have really good sensory and mind-body awareness. We thus cannot defer to this suggestion and hope the downside will simply go away. Doctors and chiropractors around the country are reporting a marked increase in Yoga-related injuries. Like it or not, Yoga has turned into a fitness trend, and whether the Yoga teacher has studied in India for 20 years or was last year’s hottest kickboxing instructor, both have potential to cause more harm than good in their Yoga teaching if the fundamental information about anatomy, limitations, and safety is not clearly understood. Let’s thus consider how to practice and teach Yoga safely so that its benefits can be enjoyed instead of compromised.I have been teaching almost every type of fitness modality on the map for the past 12 years, and I also own a national certification company (SAFAX) as well as a studio for Yoga, Pilates, Sunnlan, and personal training. I have trained literally thousands of people and to my knowledge have never had a single person injured as a result of anything I taught. Instead, I am regularly thanked for helping clients to feel better again by having exercise (and Yoga) be pain free. I do not possess a magic formula, but there are two ingredients I never teach without:1. An understanding of the human body. 2. An understanding of how to modify exercises or poses based on the individual. These are both very important points, but for now we will focus on the first, or this will become a book instead of an article! There is a vast amount of information available about the practice of Yoga, both ancient and modern. We need to realize, however, that not all of this information takes safety into account nor does it follow healthy guidelines for our neck, back, shoulders, knees, ankles, wrists, and connective tissues. In addition, we know much more about human anatomy and kinesiology today than we did in antiquity, and it is important to address all the safety issues in light of this new information. Understanding how to evaluate Yoga positions, videos, props, and books is vital. Considering the needs of special populations, such as pregnant women, children, senior citizens, beginners, and athletes, also is vitally important. Placing all special circumstances aside for now, however, let’s look at some safety basics when working with a healthy body. Preparation The purpose of a pre-activity warm-up, which may include very gentle stretching and/or rhythmic activity, is to prepare the body for more intense stretching or movement by elevating the temperature of the body, including the muscles, connective tissue, and joints so that they will function more effectively during activity. A warm-up also serves to increase circulation, which facilitates a rise in muscle temperature. This increases muscle extensibility (the ability to stretch) and elasticity (the ability to return to resting length), thereby helping to avoid injury. Deep stretches should always be reserved for later in a Yoga session, which means that classes really should not begin with adhomukha-shvanâsana (downward-facing dog) and other intense stretches. There are other factors to consider as well, but this provides the basic idea. We need increased circulation and elevated muscle temperature first. I am not suggesting that students begin by marching around the room, but I am suggesting that perhaps following some PNF (proprioceptive neuromuscular facilitation) patterns or engaging some flowing, gentle range-of-motion activities might be kinder treatment for the body. How about moving from tâdâsana (mountain) to utkâsana (chair) to tâdâsana (mountain), or moving with a dynamic vîrabhadrâsana (warrior)? You will need to adjust for your class style and mood, but the body’s basic need for preparation is constant across styles. Other Things to Think About People are not pretzels. The joints of the human body are designed to be moved in specific ways. When joint structures and surrounding support systems (ligaments, cartilage, tendons) are not respected, degeneration of the body begins and injury ratio increases. The body and its unique, wonderful design must be protected. A good deal of the Yoga that is on the market right now is potentially unsafe or unhealthy for the human anatomy. We must learn to apply the basics of safe alignment to all Yoga moves so that we can evaluate each move and decide whether or not it belongs in our practice. We must also be aware that range (how far one gets into any particular pose) is not nearly as important as form (proper alignment and safety during a pose). This is not difficult to achieve, provided there is a basic understanding of anatomy. Proceeding gently is the best approach, as it is always better to err on the gentle side. Students should be taught to ease into postures and work creatively with the body’s physical resistance. There should be no forcing of postures—Yoga is not a competitive sport and should not be accompanied by pain. Poses should be modified or stopped if there is any pain or discomfort. Everyone’s body is built differently and that must be respected. Body acceptance and empowerment should be encouraged. Stress to students that the process is far more important than the immediate result. Anatomy 101 Ligaments are bands of fibrous, supportive tissue that connect bones together and give our joints stability; all the joints in our body have ligaments. Ligaments are slightly elastic, but if they are stretched past their limit, they plasticize, meaning they do not return to their normal length, leaving the joint unstable and vulnerable to injury. A sprain is the result of an overstretched ligament. Once a ligament has been overstretched, that joint may become less stable than it was before the injury, and damage may occur when a joint moves out of its intended range of motion. With that in mind, it is clearly important to move the joints in biomechanically correct ways. From there we need to look at the major joint sites and determine how they are supposed to move as opposed to how we can force them to move. Although a commonly used definition of flexibility is “range of motion about a joint or group of joints,”[1] I tend to cringe when I hear a Yoga teacher talk about “creating flexibility of a joint.” It is the flexibility of muscles that determines healthy range of motion about a joint, and our focus and instructive dialogue should relate to increasing muscle flexibility, rather than increasing joint flexibility. Joints. The hip and shoulder are examples of a ball-and-socket joint. This is the most mobile type of joint structure. Since the hip is surrounded by large muscles, it is fairly well protected. The shoulder joint, on the other hand, is surrounded by smaller muscles, which combined with great mobility makes the shoulder somewhat unstable and more likely to have problems. The elbow and knee are examples of a hinge joint, which is meant to move in only one direction, like a door opening and closing. If this type of joint is forced to rotate, injury is likely to occur, analogous to a door coming unhinged. The wrist has more mobility than the knee or elbow because it is a condyloid joint, which can move in two directions. What we perceive as wrist rotation actually happens within the forearm between the wrist and the elbow. Like the hinge joint, the condyloid joint is not meant to rotate. A saddle joint has the same type of movements as a ball-and-socket joint but is not as freely moveable—an example is the thumb. A pivot joint just rotates—an example is where the atlas and axis meet on the cervical vertebrae (gently turn your head from side to side with the tiniest motion you can and you will feel it). Gliding joints are capable of performing small movements and help add to the movement of a joint. An example of this is the sacroiliac joint, and since it is a gliding joint injury may occur with any excessive movement. Cartilage is resilient, pliable connective tissue that absorbs shock and reduces friction between the bones of a joint. It is avascular, which means it has little or no blood supply. Because of the lack of blood supply, there is no viable way for nutrients to get to this material and help heal it if damaged. There are many types of cartilage in the body, but the primary purpose of all types is to provide bone protection, which is why you will find it most dominantly positioned at the ends of bones. Since the function of cartilage is to protect the bones from the friction produced by movement, it is continuously being worn away—a case of use it and lose it. The bad news is that this is an unavoidable part of aging. The really bad news is that we can prematurely age our cartilage through incorrect exercise and overuse! When cartilage wears away to the point that it no longer offers protection, the resulting bone-on-bone contact can be extremely painful and debilitating. The cartilage on the back of the patella can really take a beating in Yoga. Cartilage on the back of the patella is generally considered to be worn away due to repetitive motion. This may happen with improper jumping (for example, in sun salutations and between standing postures in Ashtanga Yoga). Improper landings from jumps also can affect another cartilaginous structure of the knee: the medial and lateral meniscii—little shock absorbers separating the femur from the tibia. If jumping is executed with proper alignment, and there are no preexisting conditions, there should be no problem. If not, or if the knees are not bent when landing—beware. One particular posture to pay attention to is utkatâsana (chair). If the toes are habitually pointed outward instead of parallel (so that the weight rolls onto the arch of the foot), or the knees bend outward farther than the toes, the body is improperly aligned. Over time, unequal strength will develop among the quadriceps muscles (the vastus medialis usually ends up weaker). This muscle imbalance can lead to chondromalacia patella (a softening and wearing away of the cartilage on the undersurface of the patella; editors’ note: for a general overview of this disorder see http://podiatry.curtin.edu.au/encyclopedia/chondro/chondro.html). We do need to follow the natural line of the body, but it would be more beneficial to have the student take less of a bend in the knee and just work on alignment until the legs are “retrained.” The Knee The knee joint consists of three bones—the femur, the tibia, and the patella. The femur and the tibia meet to form a hinge joint and are held together by the ligaments (medial and lateral collateral, anterior and posterior cruciate) and the joint capsule that surrounds the joint. The knee relies heavily on the ligaments and muscles for stability. When injury occurs to any structure in the knee, and pain inhibits full movements or function, the large muscles of the thigh begin to weaken and atrophy. This weakness can cause further strain on the injured area, which results in more pain and therefore more weakness. It is thus vital that any movement or stretching involving the lower body be done with the understanding that the knee joint is only meant to hinge, not rotate (torque). Consider what padmâsana (lotus) may do to this joint. Poor body mechanics and extreme knee flexion also can contribute to chondromalacia patella. Increased friction between the patella and the femur, due to overuse, improper alignment, or unequal strength between the four quadriceps muscles causing a change in tracking, can prematurely wear away the protective cartilage. This irreversible problem results in varying degrees of pain. For poses that involve sitting on the knees, support can be given by placing a towel or folded blanket between the knees or on top of the calves on which to sit. Poses that require body weight to be supported on the patella (e.g., kapotâsana [pigeon]), need to be seriously reconsidered. For some, poses such as vajrâsana (thunderbolt) and balâsana (child’s pose) can aggravate a preexisting knee problem. Sitting on a pillow can provide a simple solution. Other poses, such as those that require deep flexion at the knee joint (as in a quadriceps stretch) while holding part or all of the body weight on the patella, can significantly increase the possibility of damage. An example would be eka-pâda-rajakapotâsana (one-legged pigeon pose), and such poses would need to be modified or eliminated where indicated. The Neck The neck is comprised of the seven cervical vertebrae. Because the neck has more mobility than any other part of the spine, it requires a greater muscular support system. Since the neck can be prone to postural stress, the muscles are vulnerable to strain and are a common source of shoulder, neck, jaw, and headache pain. Poor posture can lead to adaptive shortening of the muscles and connective tissue surrounding the neck. It also can place abnormal stress on the cervical vertebrae, which can lead to joint problems such as arthritis and disc injury. Muscular imbalances in the upper back often lead to postural deviations. Both the neck and spine are abused in some of the Yoga postures you will read descriptions about or see performed in books, magazines, and videos. Headstand (shîrshâsana) and shoulder stand (sarvângâsana) are common culprits. Our neck was designed to hold up an 8-12 pound head, not a 150-pound torso, and thus if improperly done these postures can be injurious. When the body is properly aligned in shoulder stand, distribution of the weight is aligned above the shoulders, not centered over the face, which would cause compression of the cervical spine. A picture-perfect shoulder stand requires torso strength and balance, as well as flexibility in the neck and upper back. Headstand requires enough strength in the arms to support the body with little (or no weight) on the head. Weight on the head can cause compression of the intervertebral discs (see below) in the cervical spine. If the goal is to make the neck muscles stronger, there are many safer alternatives with much less risk. If there is a safer way, why would we not choose it? This consideration is not meant to overlook the physiological and psychological benefits some practitioners may experience from correctly performing headstand and shoulder stand, but to strongly caution against their incorrect use. The Back The spine is a flexible column of bones and cartilage held together by ligaments, fasciae, and muscle and consists of 24 individual moving vertebrae, each vertebra separated by a fibrocartilage disc containing a nucleus pulposus. The sacrum and the coccyx are fused vertebrae located at the base of the spine. With the spine’s great functional role in human movement, the back is vulnerable to many stresses. Injuries to the spine can involve muscles, fasciae, ligaments, the fibrocartilage discs, or the bony vertebrae themselves. Postural syndromes result from improper use of the body in daily activities, such as standing, walking, sitting, lifting, and bending. Curvatures also can be affected by obesity, pregnancy, posture, activity, trauma, and disease. All connective tissue shortens with time, and if left unstretched it can permanently adapt to the shortened position. Adaptive shortening results in abnormal stress being placed on various parts of the body. For example, tight pectoral muscles can cause forward, rounded shoulders, forcing the head into a forward position. Weak muscles also can cause postural stress because they fail to support proper spinal curve alignment. Disc injuries involve the fibrocartilage “shock absorbers” between the vertebrae. Each disc is composed of a jelly-like center (nucleus pulposus) surrounded by layers of cartilage. Positions that move the spine out of its normal curve increase pressure within the discs and place great stress on them. As a consequence, a portion of the disc may bulge, causing pressure on pain-sensitive structures. Pain may be located solely in the back or it may radiate down the arms or legs. Disc injuries also can be caused by a one-time trauma such as an accident. Disc injuries are on the rise with the increasing popularity of Yoga. Top problematic âsanas can include full bhujângâsana (cobra) (although a modified, gently repetitive cobra is a commonly prescribed treatment for some forms of lumbar disc herniation), halâsana (plow), ûrdhvamukha-shvanâsana (upward-facing dog), ushtrâsana (camel), dhanurâsana (bow), and backbends. While some of these poses can create too much spinal pressure and should be eliminated altogether for some practitioners, many of them can be modified for safer performance. When performing poses that stretch the back, students should be instructed to move slowly and gently and to elongate the spine before attempting to stretch. Proper hyperextension, or arching, should happen along the entire length of the spine. When the bend only occurs in the lumbar region of the spine, the risk for injury is far greater to that area. Similarly, dizziness that occurs in backbends often can be traced to an exaggerated curve of the cervical spine. This places pressure on the pressure receptors regulating the carotid artery, which deliver blood to the head. Keep in mind that even a “safe” pose such as shavâsana (corpse) can be uncomfortable for some people because of the lumbar pressure. Two simple solutions include bending the knees or adding a pillow under the knees. (Editors’ note: Dr. Steven Katz, a chiropractic orthopedist who specializes in treating injured Yoga teachers and students in the San Francisco Bay Area and who teaches the anatomy module of our teacher training program, shows X rays of patients with disc degeneration as early as their twenties from improper backbends, etc. When the goal becomes an ever deeper backbend rather than a properly formed backbend done as a means for growth in self-awareness and honoring the foundation yama of ahimsâ, the risk for injury is great). The Shoulder The joint between the scapula (shoulder blade) and the humerus (long bone in the upper arm) is held together primarily by an extensive system of ligaments, tendons, and muscles, which makes the shoulder versatile but unstable. The scapula is a triangular free-floating bone on the back of the rib cage. Only a short ligament holds the scapula to the clavicle, which then connects to the central skeleton. The socket of the joint is too shallow to provide bony security for the head of the humerus. This loosely connected arrangement allows for incredible mobility, yet the shoulder girdle is often asked to generate extreme force. A most common shoulder problem is shoulder impingement syndrome. In simple terms, when the elbow is lifted above shoulder height while internally rotated (lift arms overhead, with palms facing forward or palms facing out) the tendons of the rotator cuff get impinged, causing this syndrome (also called pitcher’s shoulder, swimmer’s shoulder, or tennis shoulder). This leads to other common problems such as tendinitis (irritation and inflammation of the tendons) and bursitis (inflammation of the bursa sacs that protect the shoulder). The ultimate result is pain, usually with motion, but sometimes constant. All you have to do to help eliminate this problem when the elbow is going to be lifted higher than the shoulder is externally rotate the humerus back to neutral position (also called anatomical position) (palms facing each other) or to full external rotation (palms facing backward). Think about this in relation to adhomukha-shvanâsana (downward-facing dog), pârshvottânâsana (pyramid, or lateral forward stretch), and shashânkâsana (hare). Can these poses be modified to eliminate the possibility of impingement? The Wrist The wrist is a complicated joint that can be vulnerable to repetitive movements and the stress of certain hand and arm positions. The median nerve runs from the forearm to the fingertips down a tunnel formed by the carpal bones and a layer of ligaments. If the nerve gets pinched or stressed, this can lead to carpal tunnel syndrome. Symptoms of the latter include pain in the hand or arm with weakness, numbness, tingling, and/or difficulty making a fist or grasping small objects. We therefore should be careful to avoid extreme positions for the wrist, including flexion or hyperextension, especially if accompanied by pain. Modifications should be offered for those who already have problems related to carpal tunnel syndrome. Some poses can be altered by supporting the body on the elbows instead of the hands, using the wall instead of the floor, and even changing from an open hand to a fist in order to maintain a straight wrist. What poses do you regularly teach or perform that require the arms to support the body’s weight? An entire book could be written on analyzing each pose and modifying it to suit individual needs. If we all honor the body’s design, however, we can practice yogâsana safely without requiring a book to guide us. It is a matter of learning the body’s structure, respecting it, and practicing within its design limitations. Sometimes it takes a while for new, healthy habits to form, but through patient practice, this new way of respecting the body’s design becomes not only our way of thinking, but also the way we move, share, and teach. When taking a new look at old poses, it helps to ask the following questions: • What is the purpose of exercise or stretch via Yoga postures? This may seem like an elementary question, but you would be surprised at the number of high injury risk poses that do not offer equally high benefit. • What muscles are involved? Carefully consider each one. • Is your spine in alignment, or is there excessive pressure on the discs? Remember, some safe poses will take the spine out of alignment, particularly back stretches. Watch for unnatural weight distribution that can stress the discs. • Are any of your joints in contraindicated positions? (Look for natural joint movement, and safe use of ligaments, cartilage, and tendons.) • Where is the force or weight? Is the body meant to hold that much weight in that area? • Is there any pain? Where? (Effort should be felt in the muscles and not at joint sites.) When analyzing poses, observe the entire body. Not all âsanas are for everyone. Does the potential risk of an âsana outweigh the benefits? If so, the âsana is contraindicated and should not be done. I teach exercise safety around the country, and ever so often someone tells me that he or she believes we should honor Yoga by practicing âsana in its traditional form without altering it in any way. I believe, however, that we should honor Yoga’s traditional intent while also honoring the design of the body, which we now understand more clearly. I do not think that anyone who teaches Yoga does so with intent to harm. It is, however, our responsibility to protect our students’ bodies and our own bodies and make changes where called for. We know more now, and there is no dishonor in acknowledging this and bringing the wonderful benefits of Yoga into being without having to risk injury. Endnotes [1] Alter, Michael J. Science of Flexibility. 2d ed. Champagne, Ill.: Human Kinetics, 1996. © 2003 Kaylan McKinney-Vialpando About the author: Kaylan McKinney-Vialpando has been involved in the fitness industry since 1990. She was the recipient of ESA’s National Fitness Safety Award for four years, is a faculty member for the American Council on Exercise, and is a continuing education provider for AFAA. She is currently a national master fitness workshop presenter, Director of Training for SAFAX (a national training company specializing in exercise safety), creator of Sunnlan, and a facility owner. She has been a program director and adviser since 1992 and has trained thousands of participants and trainers around the country. She has a degree in Human Services and Applied Psychology and has 14 national certifications through ACE, AFAA, ESA, and SAFAX in Yoga, Aerobics, Personal Training, Aquatics, Step, Lateral training, Kickboxing, and Fitness Consulting. Contact: zenvillage. Editors’ note: See also the recent article by Alanna Fincke, “Bent Out of Shape,” Body & Soul magazine, available online at: http://www.bodyandsoulmag.com/show_document.asp?iDocumentID=142 & iBDC=1704 & iPageNumber=1. Yogacharya Dr.Ananda Balayogi Bhavanani MBBS, ADY, DSM, DPC, PGDFH Chairman Yoganjali Natyalayam and ICYER 25,2nd Cross,Iyyanar Nagar, Pondicherry-605 013 Tel: 0413 - 2622902 / 0413 -2241561 Website: www.icyer.com SBC - Internet access at a great low price. Quote Link to comment Share on other sites More sharing options...
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