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Archive for the ‘Injuries’ Category

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As I see people strenuously doing crunches and sit-ups at the gym, alone and with trainers, here is the case made by Harvard Medical School’s Focus on Fitness e-newsletter: yoga planks are good for core fitness, sit-ups and crunches are not good for the back.

A decade ago, sit-ups and grunting crunches were the standard for tight abs and slim waistlines. But research has proven that they are not effective and may actually cause harm. The repeated sit-ups push the curved spine against the floor with pressure causing damage to the compressed discs in the small of the back. Dr. Stuart McGill’s (known for his expertise on the back) work suggests that in some people the crunches may cause herniated discs.

Sit-ups can tug on tight hip flexors that are engaged in the movement–hip flexors are muscles that run from the thighs to the lumbar vertebrae. This results in lower back pain and discomfort.

Abdominal muscles are just a small group of core muscles. So using just a small group means the rest of the muscles are not worked.

Planks do not wear and tear the vertebrae. They also engage many more muscles–on the front, sides, and back. So they strengthen the whole torso, not just the abs.

In BBC’s Future series article, The surprising downside of sit-ups, a 2011 Illinois study had one group do daily sit-ups for six weeks and the control group did none. The sit-ups  made no difference to waist size or the abdominal fat!

The BBC article states: “Research published in 2005 on soldiers stationed at the US military’s Fort Bragg attributed 56% of all the injuries sustained during the two-yearly Army Physical Fitness Test to sit-ups.”

One study suggests that it is not the wear and tear on the discs but genetics that predispose some people to back injury more than others.

Readers may also want to look at a previous post on this blog from November 7, 2011:

https://yogamedblog.wordpress.com/tag/stuart-mcgill/

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It is a fact that yoga can cause injuries. We can debate the reasons–from inadequate teaching to over zealous students. But that conversation can only begin with an acknowledgement of this basic fact that we personally know. It is a conversation I have had online with Alison Eastland, a yoga teacher and blogger, in Australia.

So we accept with openness, objectivity, and maturity when William Broad points out that women’s hips are vulnerable in his New York Times article http://www.nytimes.com/2013/11/03/sunday-review/womens-flexibility-is-a-liability-in-yoga.html. A thoughtful reflection on what is yoga, why each of us practices, how we practice is  long overdue–for teachers, schools, as well as all who practice yoga. Contraindications must be clarified, and they are not. Uninformed teachers hurt themselves as well as their students, perpetuating this state of lack of knowledge.

Men are less flexible and can get hurt from forcing the body into challenging stretches. Women are generally more flexible and can overstretch. As a couple of women said to me in one class, women who clearly know the dangers of overdoing as one has a hip replacement and the other back problems, the ego gets carried away in a class. They want to do what others around them seem to be doing. For a fleeting class, it is important to show others what they can do. This is particularly true of some middle-aged women who feel terrible about their aging bodies–acceptance is hard for them.This is in spite of repeated warnings to not look at others, to feel as if each person is totally alone in that class–nothing to prove, nothing to show-off, nothing about which to feel inadequate or insecure.

So what are the consequences of ignoring warnings? Here is what Broad writes:

To my astonishment, some of the nation’s top surgeons declared the trouble to be real — so real that hundreds of women who did yoga were showing up in their offices with unbearable pain and undergoing costly operations to mend or even replace their hips….

Dr. Hyman said his typical yoga patient was a middle-aged woman, adding that he saw up to 10 a month — or roughly 100 a year. “People need to be aware,” he said. “If they’re doing things like yoga and have pain in the hips, they shouldn’t blow it off.”

Bryan T. Kelly, an orthopedic surgeon at the Hospital for Special Surgery in Manhattan, echoed the warning, saying yoga postures were well known for throwing hips into extremes. “If that’s done without an understanding of the mechanical limitations of the joint, it can mean trouble,” he said in an interview.

Broad goes on to explain the anatomically why women’s hips are more vulnerable and it is suggested that readers read his full article to get a better understanding. It helps to be well informed.

I think (though no studies have been done), based on common sense and personal observations over 30 plus years, that gentler styles of yoga will be less prone to injury while still being significantly helpful for arthritis, range-0f-motion, backs, hips, shoulders, breathing, and many other health problems. The gentler yoga is the bedrock of Satyananda Yoga, Sivananda Yoga, Integral Yoga (all founders were disciples of Swami Sivananda of Rishikesh). Himalayan Institute founded by Swami Rama also is firmly in the gentle yoga approach. Interestingly, the founders were all grounded in raja/tantra yoga and not predominantly hatha yogis. Krishnamachari, and his most prominent disciples B.K.S. Iyengar and Pattabhi Jois, are master hatha yogis. But they too, particularly the late Krishnamachari (and now his son Desikachar), cautioned on extremes and having the right attitude and approach.

Somehow the practice of yoga has gotten out of hand and we need to fix it.

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A pilot study conducted in New Jersey tested the safety and feasibility of modified chair-yoga on functional outcome among elderly at risk for falls. Eligible participants, over 65, were from an assisted living community. All had a fall in the past six months. The staff identified them as having an increased fear of falling and therefore an increased risk of falls.

The authors conclude that yoga is a “feasible and safe intervention for elderly seniors who may be at risk in their ninth and tenth decades of life.” However, more research with extended programs is needed.

The study published in the International Journal of Yoga, Volume 5, Issue 2, 2012, pages 146-150, states:

“Falls are among the most common problems affecting older adults. At least 50% of those over 80 fall annually. The goal of this pilot study was to assess the safety and feasibility of structured yoga in an elderly population with fall risk…A chair-based yoga program was provided twice a week for 8 weeks.”

Table 1: Yoga class structure and componentsTable 1: Yoga class structure and components

Sedentary life style, a lack of physical activity, is a significant factor in loss of balance and increased risk of falls. Participating in safe physical activities that increase confidence in mobility will likely decrease fear of falling and improve balance, thereby reducing the risk of falling.

Source:

Galantino ML, Green L, DeCesari JA, MacKain NA, Rinaldi SM, Stevens ME, Wurst VR, Marsico R, Nell M, Mao JJ. Safety and feasibility of modified chair-yoga on functional outcome among elderly at risk for falls. Int J Yoga [serial online] 2012 [cited 2012 Oct 1];5:146-50. Available from: http://www.ijoy.org.in/text.asp?2012/5/2/146/98242

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Admittedly, there is some gratification in knowing that medical advice now supports what should have been part of asana teaching for decades. A 45-year old woman, a glaucoma suspect, is advised by an ophthalmolgist to avoid inverted positions such as a headstand and  “semi-inversions” such as downward dog. This was discovered in the post by the ophthalmologist Dr. Carolina Valdivia on her blog http://www.glaucoma-eye-info.com/yoga-positions.html.

With increased attention regarding yoga injuries in the main stream media, there is some openness now that did not exist some years ago. This is a welcome change for everyone. Yoga injuries are not a badge of honor or any indication of a high level of personal commitment to an asana practice. This attitude to yoga is completely misguided. The risks and limitations of asanas are still not part of most yoga teacher training programs.

Dr. Valdivia answers the following question by a 45-year old woman from New South Wales, Australia:

“Hi Dr. Valdivia. I have been very recently diagnosed as a glaucoma suspect, but at the moment my eyes are healthy. I am not taking any medication for it.

I practice yoga and my eye specialist has told me that because I am a glaucoma suspect I should not attempt any fully inverted yoga poses (legs above the head, for example: headstand) and to limit time spent in semi-inverted yoga poses and postures (head below the heart, for example: downward dog).

My question is, how many seconds can I safely hold the semi-inverted yoga poses and postures before I create an eye pressure problem?”

In response to that question. Dr. Valdivia gives an extended and thorough explanation that readers can read via the above link. However, for people who do not like to click, here are the commonly identified triggers which cause a temporary increase in intra-ocular pressure (IOP) that must be avoided not just for glaucoma but for macular degeneration, high myopia, retinal tears, and retinal detachments.

  • Abrupt or sustained physical exertion, such as lifting a heavy object.
  • Squatting.
  • Bending over, while standing or sitting, so that the head is below the heart.
  • Straining during defecation.
  • Playing a brass or woodwind musical instrument.
  • Wearing constrictive clothing around the neck.
  • Various acrobatic or gymnastic maneuvers.
  • Certain yoga positions.

 Several scientific studies have specifically investigated the effects of yoga positions on generating high intra-ocular pressure in adults. The concern has been that not only do certain yoga positions carry a risk of creating a transient eye pressure problem, these positions often are held for extended periods, which carries the risk of sustained high intra-ocular pressure.

Here is an outstanding table from Dr. Valdivia’s post that illustrates how some commonly practiced inversions increase intro-ocular pressure:

The table below presents combined (meta-analysis) data obtained from 12 published studies looking at the effects of various yoga positions on intraocular pressure (IOP). Particular emphasis is given to inverted yoga poses and those that are semi-inverted. Participants in the studies were free of ocular disease, were between the ages of 22-63 years, and ranged from intermediate to advanced levels of proficiency. Average intraocular pressure at a seated position for this combination of studies was 15.2 mmHg.

YOGA POSE

AVERAGE IOP AFTER
INITIATION

INCREASE IN IOP

Salamba Sirsasana
(headstand)
33.6 mmHg +18.4 mmHg
Urdhva padmasana
(Inverted Lotus)
33.2 mmHg +18.0 mmHg
Parsva Sirsasana
(side headstand)
33.5 mmHg +18.0 mmHg
Parivrttaikapada Sirsasana
(Revolved Split-Legged
Headstand)
33.9 mmHg +18.7 mmHg
Pincha Mayurasana (peacock
feather pose)
31.5 mmHg +16.3 mmHg
Eka Pada Viparita Dandasana (one-legged inverted-staff
pose)
28.2 mmHg +13.0 mmHg
Utthita Pada Sirsasana
(extended-leg headstand
pose)
33.7 mmHg +18.5 mmHg
Valsalva Maneuver
(attempting to forcibly exhale
while keeping the mouth and
nose closed)
38.1 mmHg +22.9 mmHg
Adho Mukha Vrksasana
(handstand)
34.8 mmHg +19.6 mmHg
Salamba Sarvangasana
(Shoulder Stand)
25.4 mmHg +10.2 mmHg
Urdhva Dhanurasana
(wheel pose)
22.4 mmHg +7.2 mmHg
Halasana (plow pose) 19.0 mmHg +3.8 mmHg
Adho Mukha Svanasana
(downward-facing dog)
19.9 mmHg +4.7 mmHg
Setu Bandha Sarvangasana
(bridge pose)
24.3 mmHg +9.1 mmHg
Urdhva Mukha Svanasana
(upward-facing dog)
14.5 mmHg -0.7 mmHg
Viparita Karani
(legs-up-the-wall pose)
14.0 mmHg -1.2 mmHg
Virasana (hero pose) 13.8 mmHg -1.4 mmHg
Padmasana (lotus pose) 13.7 mmHg -1.5 mmHg

Meta-analysis by Carolina Valdivia Cáceres, MD and Ángela Pattatucci Aragón, Ph.D., 2011.

Dr. Valdivia advises the woman:

Spikes in high intraocular pressure appear to be immediate upon entering yoga poses and postures. Thus, there appears to be no safe period of time for you to practice either inverted yoga poses or semi-inverted yoga positions.

Here we have one doctor saying no inverted or semi-inverted positions and one saying semi-inverted positions are not to be held for extended periods of time. What is “extended period of time”? To me, it is anything beyond 10-15 seconds but depending on the individual experience even that may be too much–we generally did not hold more than 5 seconds.

Why the gratification? Because ever since I have been teaching yoga, new students were asked about any medical conditions and family history of eye problems. Returning students were asked about changes in medical conditions. This way, they could be cautioned about what to avoid and modifications, where possible, could made for them. When people who said they had a family history of glaucoma (or high blood pressure, cardiac problems, GERD, high myopia, hernia, etc.) were told they could not do the only inversions we did sometimes do–the shoulderstand and the plough (a modified plough), the explanation was almost always received with disbelief. They said that no other teacher said this to them and it was taken as an unnecessary restriction that limited the physically challenging practice they wanted.

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There has been a recent spate of eye issues in our family and that presents an opportunity to discuss a serious, negative effect of certain asanas for various eye issues. A of lack of knowledge among practitioners and teachers is a matter of some concern. Contraindications of various asanas and some pranayamas should be a vital part of yoga teacher training curriculum.

It is particularly important to be aware of inversions and their effect on intra-ocular pressure (IOP)–or eye pressure. Look at the case study of a 46-year old woman, Yoga can be dangerous–glaucomatous visual field defect worsening due to postural yoga, in The British Journal of Ophthalmology, October 10, 2007 issue. The woman had worsening glaucoma a year after starting a regular practice of headstand. The effect was reversible after she stopped practicing it. In 10 non-yoga practicing volunteers, the headstand increased IOP two-fold. The study concluded:  “Therefore postural (head‐down) yoga exercises are clearly not recommended for patients suffering from glaucoma.”

To illustrate the point,  the study has pictures of the woman’s visual field some months before starting postural yoga,  one year after starting postural yoga,  and one year after stopping it.

Another study, Progression of glaucoma associated with the Sirsasana (headstand) yoga posture by researchers from the Department of Ophthalmology, University of Texas, Southwestern Medical Center in Dallas concluded: “Transient increases in IOP associated with the yoga headstand posture may lead to progressive glaucomatous optic nerve damage and visual field loss.”

In talking to ophthalmologists and a retinologist, it is clear that they have deep concerns regarding inversions and particularly when the inversions are held for prolonged periods.

Source:

Br J Ophthalmol. 2007 October; 91(10): 1413–1414.

PMID: 17276961 [PubMed – indexed for MEDLINE]

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The results of the study in the previous post are in line with expectations. Studies often raise more questions and the blog has received several questions on how to practice surya namaskar. I hope this answers the questions.

1. How does one define slow versus fast surya namaskar?

I don’t think that the study in the previous blog post refers to the extremely dynamic styles where you jump from one asana to another. These are not yet that popular in India as they are in the West. So “fast” to me means keeping a constant flow, without pause, taking 2-3 seconds from asana to asana. “Slow” could mean 5-6 seconds and more.

It would be helpful for the terms (including slow and fast) to be clarified in any study. As there are so many different styles, some explanation about what constitutes “aerobic” and what is “yogic” is also essential. How many rounds did the participants do? When were the various measurements made–immediately after the practice, or after a defined interval, or at the end of the six-month study? What time of the day did the children practice? Perhaps yoga research journal editors might see this post and think about these points when publishing articles!

2. Can one alternate between slow and fast surya namaskar?

Yes. Some days your body will tell you what it feels like doing.

As mentioned in the summer yoga blog post, I do not recommend surya namaskar in very hot summers. But if people still feel the need to do it, the practice must be done early morning and slowly. The body’s metabolism must not be overheated in the summer.

Conversely, in cold winters, fast surya namaskars are helpful in speeding the metabolism and balancing out the tamasic inertia with the rajasic activity. Fast surya namaskars can be very helpful for the winter blues, for depression, warming up the body, improving circulation, and sometimes increasing appetite.

 3. Can slow and fast surya namaskars be combined?

Yes. I often taught a combination practice. Begin with a couple of slow rounds, then do two-three fast rounds, and then cool off with a slow round.

4. How does one incorporate mantras?

Surya namaskar is wonderful when practiced with surya mantras. This would be a slower practice. When done with bija mantras (seed sounds) it becomes a fast practice. The body flows effortlessly to the rhythm of the mantras and people find themselves being able to do more rounds with the mantras than they could without them. The only caution is to be careful not to overstretch. In my years of teaching, even if people have no idea of what the mantras mean, they still love the vibrations of the mantras and how their body/mind responds to them.

5. How should the surya namaskar practice end after several rounds?

It is essential to then practice shavasana and body awareness till the heart beat and breath have settled down completely–spend 5 minutes in shavasana.

This can be followed by a pranayama practice. There are some audio tracks on www.mahasriyoga.com/pranayama.  A Yoga Nidra is also good and several audio tracks are on www.mahasriyoga.com/meditation. Particularly around the holidays, Candle Flame Trataka can be an effective practice–the audio track is on the website as a meditation track. All content and audio tracks are free.

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Here are some reminders for summer yoga:

Avoid doing asanas in direct sunlight, except at dawn or dusk.

Do not do dynamic sun salutations, especially 12 rounds. It may overheat the body.  Switch to a more passive sequence that allows the body time to settle and rest in each asana for a comfortable amount of time.

Chair yoga is not strenuous and if your body is comfortable with it, it is fine to practice in a comfortable, cool room.

Avoid agnisar, bhastrika, kapalbhati, and surya bhedha. Instead practice sitali and seetkari, the two cooling breaths. Non-heating breaths are fine.

Happy July4th!

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